State of Georgia Department of Community Health SFY 2012 EXTERNAL QUALITY REVIEW ANNUAL REPORT INCLUDING CY 2010 PERFORMANCE MEASURES SFY 2011 REPORTED PERFORMANCE IMPROVEMENT PROJECTS SFY 2012 COMPLIANCE REVIEWS for Georgia Families Care Management Organizations June 2012 3133 East Camelback Road, Suite 300 Phoenix, AZ 85016 Phone 602.264.6382 Fax 602.241.0757 CONTENTS 1. Executive Summary ..................................................................................................................... 1-1 Purpose of Report .......................................................................................................................... 1-1 Overview of the External Quality Review ........................................................................................ 1-2 Overall Findings, Conclusions, and Recommendations .................................................................. 1-2 Quality ........................................................................................................................................ 1-3 Access ........................................................................................................................................ 1-4 Timeliness................................................................................................................................... 1-5 Conclusions ................................................................................................................................ 1-5 Recommendations ...................................................................................................................... 1-6 2. Background and Overview .......................................................................................................... 2-1 Georgia Medicaid Managed Care Service Delivery System Overview ............................................ 2-1 Georgia Families Care Management Organizations ....................................................................... 2-2 AMERIGROUP Community Care ................................................................................................ 2-2 Peach State Health Plan ............................................................................................................. 2-2 WellCare of Georgia, Inc............................................................................................................. 2-2 Georgia Families Quality Strategy .................................................................................................. 2-2 Georgia Families Quality Initiatives Driving Improvement ............................................................... 2-3 Auto-Assignment Program .......................................................................................................... 2-3 Quality Improvement Conference................................................................................................ 2-4 Performance Improvement Project Methodology Changes ......................................................... 2-4 CHIPRA Reporting ...................................................................................................................... 2-4 Medicaid Redesign ..................................................................................................................... 2-5 3. Review of Compliance With Standards ...................................................................................... 3-1 Review of Compliance With Standards........................................................................................... 3-1 Findings ......................................................................................................................................... 3-1 Findings ......................................................................................................................................... 3-3 CMO Comparison Key Findings.................................................................................................. 3-4 Follow-Up Reviews of 20092010 Compliance Review Findings.................................................... 3-7 4. Performance Measures ................................................................................................................ 4-1 Performance Measure Requirements and Targets ......................................................................... 4-1 Findings ......................................................................................................................................... 4-2 Performance Measure Validation Key Findings........................................................................... 4-2 Performance Measure Result Findings ....................................................................................... 4-3 CMO Comparison Key Findings................................................................................................ 4-10 Conclusions .............................................................................................................................. 4-18 Recommendations .................................................................................................................... 4-19 5. Performance Improvement Projects ........................................................................................... 5-1 Validation of Performance Improvement Projects ........................................................................... 5-1 Findings ......................................................................................................................................... 5-3 Performance Improvement Project Validation Key Findings ........................................................ 5-3 CMO Comparison Key Findings.................................................................................................. 5-4 Outcome Results ........................................................................................................................ 5-5 Conclusions ................................................................................................................................ 5-8 Recommendations ...................................................................................................................... 5-8 6. CMO-Specific Follow-Up on Prior-Year Recommendations ...................................................... 6-1 Introduction .................................................................................................................................... 6-1 AMERIGROUP Community Care ................................................................................................... 6-1 SFY 2012 External Quality Review Annual Report State of Georgia Page i GA2011-12_EQR_AnnRpt_F2_0612 CONTENTS Review of Compliance With Operational Standards .................................................................... 6-1 Validation of Performance Improvement Projects........................................................................ 6-2 Validation of Performance Measures .......................................................................................... 6-3 Peach State Health Plan ................................................................................................................ 6-3 Review of Compliance With Operational Standards .................................................................... 6-3 Validation of Performance Improvement Projects........................................................................ 6-4 Validation of Performance Measures .......................................................................................... 6-5 WellCare of Georgia, Inc. ............................................................................................................... 6-5 Review of Compliance With Operational Standards .................................................................... 6-5 Validation of Performance Improvement Projects........................................................................ 6-6 Validation of Performance Measures .......................................................................................... 6-6 Appendix A. Methodology for Reviewing Compliance With Standards........................................A-1 Appendix B. Methodology for Conducting Validation of Performance Measures .......................B-1 Appendix C. Methodology for Conducting Validation of Performance Improvement Projects...C-1 SFY 2012 External Quality Review Annual Report State of Georgia Page ii GA2011-12_EQR_AnnRpt_F2_0612 1. Executive Summary Purpose of Report The Georgia Department of Community Health (DCH) is responsible for administering the Medicaid managed care program and the Children's Health Insurance Program (CHIP) in the State of Georgia to approximately 1.1 million beneficiaries.1-1 DCH contracts with three privately owned managed care organizations, referred to by the State as care management organizations (CMOs), to deliver services to members who are enrolled in the State's Medicaid and CHIP programs. The State refers to its Medicaid managed care program as Georgia Families and to its CHIP program as PeachCare for Kids. For the purposes of this report, Georgia Families refers to all Medicaid and CHIP members enrolled in managed care. The Code of Federal Regulations (CFR) at 42 CFR 438.3581-2 requires that states use an external quality review organization (EQRO) to prepare an annual, independent technical report that analyzes and evaluates aggregated information on the quality, timeliness of, and access to the health care services that managed care organizations provide. The technical report must describe how the EQRO drew conclusions as to the quality, timeliness of, and access to care furnished by a state's managed care organizations. The report of results must also contain an assessment of the strengths and weaknesses of the managed care organizations regarding health care quality, timeliness, and access and must make recommendations for improvement. Finally, the report must assess the degree to which the managed care organizations addressed recommendations made within the previous external quality review (EQR). To comply with these requirements, DCH contracted with Health Services Advisory Group, Inc. (HSAG), an EQRO, to aggregate and analyze the Georgia Families CMOs' data and prepare an annual technical report. This report provides: An overview of the Georgia Families program. A description of the scope of EQR activities included in this report. An aggregate assessment of health care timeliness, access, and quality across CMS-required mandatory activities for compliance with standards, performance measures, and quality improvement projects. CMO-specific findings and an assessment of CMO strengths and weaknesses. Recommendations to DCH to improve the CMOs' compliance with State and federal requirements that will subsequently lead to improvements in the quality, timeliness, and access to services provided to Georgia Families members. 1-1 Georgia Department of Community Health. Georgia Families Quality Strategic Plan--Update, November 2011. 1-2 Department of Health and Human Services, Centers for Medicare & Medicaid Services. Federal Register/Vol. 68, No. 16/Friday, January 23, 2003/Rules and Regulations, p. 3597. 42 CFR Parts 433 and 438 Medicaid Program; External Quality Review of Medicaid Managed Care Organizations, Final Rule. SFY 2012 External Quality Review Annual Report State of Georgia Page 1-1 GA2011-12_EQR_AnnRpt_F2_0612 EXECUTIVE SUMMARY Recommendations for the CMOs to improve member access to care, quality of care, and timeliness of care. Overview of the External Quality Review To produce this report, HSAG analyzed and aggregated data submitted and/or gathered by the CMOs. The data addressed the following three federally mandated EQR activities: Review of compliance with federal and State-specified operational standards. HSAG evaluated the CMOs' compliance with State and federal requirements for organizational and structural performance. The DCH contracts with the EQRO to conduct a review of one-third of the full set of standards each year in order to complete the cycle within a three-year period of time. HSAG conducted on-site compliance reviews in August 2011. The CMOs submitted documentation that covered the State Fiscal Year (SFY) 2011 review period of July 1, 2010, through June 30, 2011. HSAG provided detailed, final audit reports to the CMOs and DCH in February 2012. Validation of performance measures. HSAG validated performance measures required by DCH to evaluate the accuracy of the performance measure results reported by the CMOs. The validation also determined the extent to which the DCH-specific performance measures calculated by the CMOs followed specifications established by DCH. HSAG assessed performance measure results and their impact on improving the health outcomes of members. HSAG began performance measure validation of the CMOs in February 2011 and completed validation in June 2011. The CMOs submitted performance measure data that generally reflected the period of January 1, 2010, through December 31, 2010. HSAG provided final performance measure validation reports to the CMOs and DCH in July 2011. In addition to validation of the CMO data, DCH used HSAG to perform performance measure validation of its medical management information system's (MMIS) vendor, Hewlett Packard (HP), to determine compliance with generating rates for the Georgia Families Program, the Fee-forService Program, and for all members enrolled in Medicaid and CHIP. Validation of performance improvement projects (PIPs). HSAG reviewed PIPs for each CMO to ensure the CMOs designed, conducted, and reported projects in a methodologically sound manner consistent with the CMS protocols for validating PIPs. HSAG assessed the PIPs for real improvements in care and services to give confidence to the reported improvements. In addition, HSAG assessed the CMOs' PIP outcomes and impacts on improving care and services provided to members. HSAG began PIP validations in July 2011 and completed validations in September 2011. The CMOs submitted PIP data that reflected varying time periods, depending on the PIP topic. HSAG provided final, CMO-specific PIP reports to the CMOs and DCH in October 2011. Overall Findings, Conclusions, and Recommendations The Centers for Medicare & Medicaid Services (CMS) chose the domains of quality, access, and timeliness as keys to evaluating the performance of Medicaid managed care plans. In this report, HSAG provides overall findings, conclusions, and recommendations regarding the CMOs' aggregate performance during the review period for each domain of care. SFY 2012 External Quality Review Annual Report State of Georgia Page 1-2 GA2011-12_EQR_AnnRpt_F2_0612 EXECUTIVE SUMMARY Quality The quality domain of care relates to the CMOs' structural and operational characteristics and their ability to increase desired health outcomes for Georgia Families' members (through the provision of health care services). Performance measures and PIP results are used to assess care delivered to members by the CMOs in areas such as preventive screenings and well-care visits, management of chronic disease and appropriate treatment for acute conditions. Interventions associated with increasing performance in these areas are likely to improve health outcomes. In addition, DCH monitors aspects of each CMO's operational structure that support the delivery of quality care including: the adoption of practice guidelines by each plan's contracted providers, the effectiveness of each plan's quality assessment and performance improvement program, and the assessment of each CMO's health information system used to support the delivery of care and services. HSAG used the CMOs' performance measure rates (which reflect Calendar Year (CY) 2010 measurement data), PIP validation results and outcomes, and scores from the review of compliance with standards related to measurement and improvement to assess the quality domain of care. The DCH required the CMOs to report on a total of 33 performance measures. Many of the 33 performance measures have multiple components (such as the hemoglobin A1C testing, retinal eye exam, and blood pressure reading components of the Comprehensive Diabetes Care measure) or include age stratifications. The DCH established performance targets specific to the performance measures as well as for some of the measures' components. The CMO performance measure results showed that the overall CY 2010 CMO weighted average rates met four of the CY 2010 performance targets. These included: the Annual Dental Visit measure for the Ages 23 Years and Ages 221 Years age stratifications; Comprehensive Diabetes Care for the HbA1c Control (<8.0) component; and Follow-Up Care for Children Prescribed ADHD Medication for the Continuation and Maintenance Phase component. When comparing measures with both CY 2009 and CY 2010 rates, the CMO weighted average rates showed statistically significant improvement for seven rates, and while many rates did not meet performance targets or show statistically significant improvement, most CY 2010 rates were improved over CY 2009 rates. Despite some CMO success during the year, many opportunities for improvement exist for the CMOs as a whole. The greatest opportunity for improvement exists in the quality of care performance measures--those that reflect care being given that is consistent with clinical practice guidelines across the domains of care. The CMOs are improving aspects of care that relate to services being provided and access to care; however, managing member health outcomes warrants additional focus. Individual CY 2010 CMO performance showed that AMERIGROUP achieved some of the highest performance measure rates when compared with the rates reported by Peach State and WellCare. AMERIGROUP met eight of the CY 2010 performance targets, followed by WellCare, which met five of the targets, and Peach State, which met two of the targets. Peach State demonstrated higher performance than AMERIGROUP in the area of Immunizations for Adolescents (no data were SFY 2012 External Quality Review Annual Report State of Georgia Page 1-3 GA2011-12_EQR_AnnRpt_F2_0612 EXECUTIVE SUMMARY reported by WellCare for this measure), and WellCare demonstrated the highest performance in the area of Comprehensive Diabetes Care. The review of compliance with standards showed that all of the CMOs scored 100 percent on the standard for coordination and continuity of care, demonstrating that the CMOs have the appropriate structure to support the administration of care management and disease management programs. In subsequent years, HSAG will shift its focus from structure, administration, and documentation compliance to a more thorough evaluation of the application of these programs and member health care outcomes. Performance improvement project results related to quality of care showed mixed results. The CMOs did best on validation elements related to documentation of the study design and implementation but fell short on elements that measure statistically significant improvement and sustained improvement. Approximately 46 percent of PIPs achieved statistically significant improvement, leaving slightly more than half that did not show improvement. DCH worked to modify the PIP validation methodology to place greater scoring emphasis on PIP outcomes. This methodology change should help increase the CMOs' accountability and narrow the focus to achieve health care outcomes versus compliance with documentation. Access The access domain of care relates to a CMO's standards, established by the State, to ensure the availability of and access to all covered services for Georgia Families members. The DCH contracts require the CMOs to ensure access to and the availability of services to members. In addition to its own internal monitoring activities, DCH uses HSAG to conduct monitoring processes, including audits, to assess CMO compliance with access standards. The assessment of compliance with these access standards evaluates whether the CMOs have an adequate network to provide all contractually required services. Network adequacy assessments demonstrate whether there are appropriate numbers and types of providers within the CMOs' provider networks. These access compliance assessments also evaluate the availability of the services (as measured by appointment wait times), coordination and continuity of care, and coverage of services. Additionally, many performance measures reported by the CMOs fall under more than one domain of care. Measures such as well-care visits for children and adolescents, childhood immunizations, timeliness of prenatal care and postpartum care, cancer screening, and diabetes care fall under both quality and access because members rely on access to and the availability of these services to receive care according to generally accepted clinical guidelines. Member satisfaction results also provide useful information to evaluate access to care. The CMOs' CY 2010 performance measure rates showed that the CMOs as a whole performed best in the area of access. Based on the CMOs' weighted average results, two of the four CY 2010 access performance targets were met. Those targets were for the Annual Dental Visit total member rate (221 years of age) and the rate for members 23 years of age. In addition, the CMOs improved their rates for adolescents' access to a primary care provider and dental visits across age groups. SFY 2012 External Quality Review Annual Report State of Georgia Page 1-4 GA2011-12_EQR_AnnRpt_F2_0612 EXECUTIVE SUMMARY The compliance review showed 100 percent scores for all CMOs for availability of services. Despite having the appropriate availability of services, the CMOs had more challenges with the requirements related to the furnishing of services to members. Many of the CMOs had findings and recommendations for monitoring appointment wait times and meeting the established thresholds for number and types of providers within the network and within geographic boundaries. Difficulty accessing services can impact a Georgia Families member's ability to obtain medically necessary services and/or delay him/her from receiving those services within the appropriate time frames. Consistent with the prior year's results, the CMOs continue to have opportunities to improve in the area of access for women's health for cancer screening services and prenatal and postpartum care. The CMOs should determine the structural barriers (such as the distance from screening locations, limited hours of operation, lack of day care for children, and language and cultural factors) that prevented members from accessing these services. Timeliness The timeliness domain of care relates to the CMOs' ability to: make timely utilization decisions based on the clinical urgency of the situation, minimize any disruptions to care, and provide a health care service quickly after a need is identified. The DCH CMO contracts require that CMOs ensure timeliness of care. HSAG conducts review activities to assess the CMOs' compliance with these standards in areas such as: enrollee rights and protections, the grievance system, continuity and coordination of care, and utilization management. Performance measures such as childhood immunizations, well-care visits, and prenatal and postpartum care fall under the timeliness domain of care because they relate to the provision of a health care service within a recommended period of time after a need is identified. Members' satisfaction with receiving timely care also falls under the timeliness domain of care. The CMOs' CY 2010 weighted average performance measure rates relative to timeliness of care demonstrated some improvements over the CY 2009 rates; however, as noted above, many opportunities exist to meet DCH-established performance targets. The compliance reviews revealed that the CMOs have some opportunities to improve in the areas of coverage and authorization, as well as emergency and poststabilization services. For coverage and authorization, the review showed that the CMOs were making decisions within the appropriate time frames; however, not all required documentation was included in the notice of action letters. Some of the CMOs' documents were not consistent with how poststabilization care was being requested, authorized, and communicated to members and providers. Conclusions Based on a review of performance measure results, PIP outcomes, and compliance with State and federal standards, HSAG found that the CMOs had organizational structures and resources to support the quality, timeliness of, and access to care delivered to its Georgia Families members. However, the CMOs have a continued opportunity to demonstrate better application/implementation, measurement, SFY 2012 External Quality Review Annual Report State of Georgia Page 1-5 GA2011-12_EQR_AnnRpt_F2_0612 EXECUTIVE SUMMARY monitoring, and evaluation of care and service delivery across activities. These actions will yield a greater likelihood of success with improving actual health outcomes. Recommendations Based on the review of the CMOs' performance on the performance measure results, PIP outcomes, and compliance with State and federal standards, HSAG provides the following global recommendations. Specific recommendations based on each activity's review findings are included at the end of each section. DCH should continue to work with the CMOs on grouping common areas for intervention, such as well-child and well-care visits as a strategy to improve outcomes across several measures. At DCH's request, HSAG will work in collaboration with DCH to develop a focused methodology for conducting the compliance reviews during SFY 2013 to incorporate the review of outcome data. HSAG will formally adopt the PIP scoring methodology changes for SFY 2013 that place greater emphasis on improved health outcomes to increase CMO accountability. DCH and the CMOs may consider using the EQRO to provide greater technical assistance and facilitation of collaborative efforts to help drive improved performance through a structured quality improvement approach. HSAG will evaluate DCH's and the CMOs' progress in the next annual report. SFY 2012 External Quality Review Annual Report State of Georgia Page 1-6 GA2011-12_EQR_AnnRpt_F2_0612 2. Background and Overview Georgia Medicaid Managed Care Service Delivery System Overview DCH was created in 1999 to serve as the lead agency for health care planning and purchasing issues in Georgia. The General Assembly created DCH by consolidating four agencies involved in purchasing, planning and regulating health care. As the largest division in the Department of Community Health, the Medicaid Division administers the Medicaid and CHIP programs, which provide health care for children, pregnant women, and people who are aged, blind, and disabled. The Department is designated as the single State agency for Medicaid. The State of Georgia implemented its Georgia Families program in 2006. Georgia Families delivers health care services to Medicaid and CHIP (PeachCare for Kids) members within a managed care model. Through its three CMOs that DCH selected in a competitive bid process, DCH provides services to individuals enrolled in its Georgia Families program. By providing a choice of health plans, Georgia Families allows members to select a CMO that fits their needs. DCH contracted with each CMO to deliver services within three or more of the six designated geographic regions. To ensure a smooth and successful transition from fee for service to the Georgia Families managed care program, DCH implemented the program in two phases, beginning with two of the six regions (Atlanta and Central) on June 1, 2006, followed by the remaining four regions (North, East, Southeast, and Southwest) on September 1, 2006. DCH awarded contracts to at least two CMOs within each of the six geographic regions. The Georgia Families program includes more than half of the State's Medicaid population and a majority of the State's PeachCare for Kids population. Enrollment is mandatory for all PeachCare for Kids members and for the following Medicaid eligibility categories: Low-Income Medicaid (LIM) program Transitional Medicaid Pregnant women and children in the Right from the Start Medicaid (RSM) program Newborns of Medicaid-covered women Refugees Women with breast and cervical cancer Women participating in the Planning for Healthy Babies (P4HB) program SFY 2012 External Quality Review Annual Report State of Georgia Page 2-1 GA2011-12_EQR_AnnRpt_F2_0612 BACKGROUND AND OVERVIEW Georgia Families Care Management Organizations DCH held contracts with three CMOs during the review period of July 1, 2010, through June 30, 2011. All three CMOs provide services to the State's Georgia Families members. In addition to providing medical and mental health Medicaid and CHIP-covered services to members, the CMOs also provide a range of enhanced services, including dental and vision services, disease management and education, and wellness/prevention programs. AMERIGROUP Community Care AMERIGROUP Community Care (AMERIGROUP) is a wholly-owned subsidiary of AMERIGROUP Corp., a multistate managed health care company serving people who receive health care benefits through publicly sponsored programs, including Medicaid and CHIP. AMERIGROUP serves members in the Atlanta, East, North, and Southeast regions. Peach State Health Plan Peach State Health Plan (Peach State) is part of the multistate national parent company, Centene Corp. Peach State serves members in the Atlanta, Central, and Southwest regions. WellCare of Georgia, Inc. WellCare of Georgia, Inc., (WellCare) is part of the national corporation, WellCare Health Plans, Inc., a multistate provider of only government-sponsored health products. WellCare serves members in all of the regions (i.e., Atlanta, Central, East, North, Southwest, and Southeast). Georgia Families Quality Strategy Federal regulations require that state Medicaid agencies develop and implement a written quality strategy for assessing and improving the quality of health care services offered to their members. The written strategy must describe the standards the state and its contracted plans must meet. The state must conduct periodic reviews to examine the scope and content of its quality strategy, evaluate its effectiveness, and update it as needed. To comply with federal regulations, DCH submitted to CMS its initial Georgia Families Quality Strategic Plan in June 2007 for ensuring that the Department provided timely, accessible, and quality services to members of Georgia Families. The Plan was approved by CMS in 2008, and a quality strategic plan update was completed in January 2010 and again in November 2011.2-1 DCH publishes the updated plans on its Web site. 2-1 Georgia Department of Community Health. Georgia Families Quality Strategic Plan Update, November 2011. SFY 2012 External Quality Review Annual Report State of Georgia Page 2-2 GA2011-12_EQR_AnnRpt_F2_0612 BACKGROUND AND OVERVIEW The 2011 Update: Highlighted major accomplishments since the 2010 update, including: The implementation of the new Georgia Medicaid Management Information System (GAMMIS). Approval of an 1115 Demonstration application to CMS to reduce low birth weight rates in Georgia. Alignment of the EPSDT periodicity schedule for both fee-for-service (FFS) and Georgia Families programs. Establishment of a Patient Centered Medical Home (PCMH) work group. Initiation of a collaborative PIP on avoidable emergency room utilization. Participation in the Medicaid redesign initiative. Outlined opportunities for improvement related to quality improvement efforts. Described for each of DCH's new goals its performance-driven objectives designed to demonstrate success or to identify challenges in meeting intended outcomes related to providing quality, accessible, and timely services. The four goals were described as: Promotion of an organization-wide commitment to quality of care and services. Improvement and enhancement of the quality of patient care provided through ongoing, objective, and systematic measurement, analysis and improvement of performance. Promotion of a system of health care delivery that provides coordinated and improved access to comprehensive health care and enhanced provider and client satisfaction. Promotion of acceptable standards of health care within the managed care program by monitoring internal/external processes for improvement opportunities. In SFY 2011, DCH continued to align the Georgia Families' quality initiatives and EQR review with the revised quality strategy. DCH used recommendations in the EQR technical report as part of its process to assess the effectiveness of its strategic goals and objectives and provide a road map for potential changes and new goals and strategies. Georgia Families Quality Initiatives Driving Improvement HSAG noted several DCH initiatives that supported the improvement of quality of care and services for Georgia Families members, as well as activities that supported the CMOs' improvement efforts. Auto-Assignment Program DCH continued its auto-assignment program, which began in 2010. The program awards the CMOs with increased default enrollment based on a cost/quality indicator methodology and encourages the CMOs to achieve better quality outcomes for their members. For the CY 2011 auto-assignments, DCH selected the following six clinical performance measures to determine the quality scores: Well-Child Visits in the First 15 Months of Life--Six or More Visits Adolescent Well-Care Visits SFY 2012 External Quality Review Annual Report State of Georgia Page 2-3 GA2011-12_EQR_AnnRpt_F2_0612 BACKGROUND AND OVERVIEW Follow-Up After Hospitalization for Mental Illness (7-Day Follow-Up) Childhood Immunization Status--Combination 2 Lead Screening in Children Comprehensive Diabetes Care--HbA1c Testing Quality Improvement Conference DCH worked with HSAG to conduct a quality improvement conference, Telling The Georgia Families Story, in April 2011. The focus of the conference was to provide technical assistance to the CMOs to facilitate their achievement of improved health outcomes for their members. The format for the half-day meeting brought together representatives from all CMOs. Facilitated discussion during strategy sessions provided the CMOs an opportunity to identify barriers and potential strategies for implementation. The conference resulted in the CMOs' initiating work on a collaborative performance improvement project aimed at reducing avoidable emergency department utilization. Performance Improvement Project Methodology Changes DCH requested that HSAG propose enhancements to the PIP validation scoring methodology that would yield a stronger connection between an overall Met validation status and improved health outcomes. DCH noted that, while the CMOs continued to receive Met validation scores for producing valid and reliable PIPs, few projects resulted in actual improvement. HSAG modified its validation scoring to make achievement of statistically significant improvement and then sustained improvement critical elements to receive an overall Met validation status. The CMOs' PIPs that underwent validation between July 1, 2011, and September 30, 2011, were scored using the old and new methodologies. HSAG will adopt the new scoring methodology in subsequent years to transition the CMOs from documentation compliance to improved health outcomes. DCH is a State leader in requiring this transition. CHIPRA Reporting DCH was spotlighted by CMS for their quality of care reporting in the September 2011 Department of Health and Human Services Secretary's Report. The State of Georgia collected and reported the most CHIPRA Initial Core Set measures of any state for its Medicaid and CHIP populations. DCH continues to modify its required performance measure set and methodology to align with the CHIPRA Core Set measures and specifications. Additionally, DCH used its MMIS vendor to calculate rates, including hybrid rates, for its Georgia Families and Fee-For-Service populations for the first time during this reporting period, which reflected CY 2010 data. This demonstrates a strong commitment from DCH to improve health care outcomes for the entire Medicaid and CHIP populations, further aligning with its Quality Strategy goals. SFY 2012 External Quality Review Annual Report State of Georgia Page 2-4 GA2011-12_EQR_AnnRpt_F2_0612 BACKGROUND AND OVERVIEW Medicaid Redesign DCH contracted with an external vendor, Navigant Consulting, to perform an assessment of the Medicaid and CHIP programs and make recommendations for a redesign of those programs. Internal DCH staff, CMO staff, EQR staff, and other key stakeholders were included in the assessment process. The goal of the assessment was to identify potential redesign options and assess the extent to which the options will meet DCH's goals. National and Georgia-specific environmental scans were conducted as part of the assessment process. Note: While Navigant's report was released in 2012, outside of the scope of this review period, it was available prior to the finalization of this report and can be found on DCH's Web site.2-2 Navigant identified three redesign options for DCH to consider for implementation. The next step in the redesign process will be for DCH to obtain additional stakeholder input on the recommended options, review and analyze the report, and finalize the redesign model that will be implemented. 2-2 The Medicaid and Peach Care for Kids Design Strategy Report can be found at: http://dch.georgia.gov/00/channel_title/0,2094,31446711_175210527,00.html. SFY 2012 External Quality Review Annual Report State of Georgia Page 2-5 GA2011-12_EQR_AnnRpt_F2_0612 3. Review of Compliance With Standards Review of Compliance With Standards DCH contracted with HSAG to perform a review of the CMOs' compliance with standards, one of the three federally mandated activities. The requirements described at 42 CFR 438.358 specify that a review must be conducted within a three-year period to assess the CMOs' compliance with State and federal requirements related to enrollee rights and protections, access to services, structure and operations, measurement and improvement, and grievance system standards. HSAG reviews onethird of this full set of standards each year so that over a three-year cycle, all requirements will be reviewed. HSAG conducted on-site compliance reviews in August 2011. The CMOs submitted documentation that covered the review period of July 1, 2010, through June 30, 2011. HSAG provided detailed, final audit reports to the CMOs and DCH in February 2012. During this cycle, HSAG reviewed the CMOs' performance in the following areas related to access to services: Availability of Services Furnishing of Services Cultural Competence Coordination and Continuity of Care Coverage and Authorization of Services Emergency and Poststabilization Services Appendix A contains a detailed description of HSAG's methodology for conducting the review. Findings HSAG organized, aggregated, and analyzed results from the compliance reviews to draw conclusions about the CMOs' performance in providing quality, accessible, and timely health care services to Georgia Families members. Table 3-1 displays the standards and compliance scores. Standard # I II Table 3-1Standards and Compliance Score Standard Name # of Elements* # of Applicable Elements** # Met*** # Partially Met # Not Met A: 17 A: 0 A: 0 Availability of Services 17 17 P: 17 P: 0 P: 0 W: 17 W: 0 W: 0 Furnishing of Services 22 A: 12 A: 9 A: 1 22 P: 16 W: 17 P: 5 W: 4 P: 1 W: 1 # Not Applicable A: 0 P: 0 W: 0 A: 0 P: 0 W: 0 Total Compliance Score A: 100% P: 100% W: 100% A: 75% P: 84% W: 86% SFY 2012 External Quality Review Annual Report State of Georgia Page 3-1 GA2011-12_EQR_AnnRpt_F2_0612 REVIEW OF COMPLIANCE WITH STANDARDS Standard # III Standard Name Cultural Competence Table 3-1Standards and Compliance Score # of Elements* # of Applicable Elements** # Met*** # Partially Met # Not Met A: 14 A: 0 A: 0 14 14 P: 14 W: 14 P: 0 W: 0 P: 0 W: 0 # Not Applicable A: 0 P: 0 W: 0 Total Compliance Score A: 100% P: 100% W: 100% A: 13 A: 0 A: 0 A: 0 A: 100% IV Coordination and Continuity of Care 13 13 P: 13 W: 13 P: 0 W: 0 P: 0 W: 0 P: 0 W: 0 P: 100% W: 100% Coverage and V Authorization of Services Emergency and VI Poststabilization Services Totals A: 24 A: 1 A: 0 A: 0 A: 98% 25 25 P: 23 W: 21 P: 1 W: 4 P: 1 W: 0 P: 0 W: 0 P: 94% W: 92% A: 19 A: 1 A: 0 A: 0 A: 98% 20 20 P: 17 W: 19 P: 3 W: 1 P: 0 W: 0 P: 0 W: 0 P: 93% W: 98% A: 99 A: 11 A: 1 A: 0 A: 94% 111 111 P: 100 W: 101 P: 9 W: 9 P: 2 W: 1 P: 0 W: 0 P: 94% W: 95% ****Total Compliance Score Across the Six Standards A: 94% P: 94% W: 95% * Total # of Elements: The total number of elements in each standard. ** Total # of Applicable Elements: The total number of elements within each standard minus any elements that received a designation of NA. *** AMERIGROUP (A); Peach State (P); WellCare (W) **** Total Compliance Score: The overall percentages were calculated by adding the number of elements that received a score of Met to the weighted (multiplied by 0.50) number that received a score of Partially Met, then dividing this total by the total number of applicable elements. For standards assessed during the review period, HSAG found that performance for all three CMOs on each of the 111 applicable requirements across the three standards was sufficient to result in an overall Met score. The CMOs had ample documentation describing their processes, practices, action plans, and performance results/outcomes related to each review requirement. During the on-site interviews, the responses of the CMOs' staff members to HSAG's questions, including their descriptions and examples of their processes and practices for ensuring compliance with the requirements, were consistent with the documentation. The statewide percentage-of-compliance score for WellCare was 95 percent, while both AMERIGROUP and Peach State scored 94 percent. All three scores reflect commendable CMO performance. SFY 2012 External Quality Review Annual Report State of Georgia Page 3-2 GA2011-12_EQR_AnnRpt_F2_0612 REVIEW OF COMPLIANCE WITH STANDARDS Following its review, HSAG prepared an initial draft report of its findings and forwarded it to DCH and the CMOs for their review prior to issuing this final report. During its review, DCH noted some discrepancies between HSAG-audited results and reports submitted by the CMOs to DCH. DCH affirms that HSAG scored some areas of the review as compliant based on HSAG's evaluation of the CMOs' structure and operations against federal regulatory provisions and State contract requirements. However, outcome data and monitoring reports provided by the CMOs to DCH suggested additional areas in need of improvement for the CMOs to attain desired outcomes. As DCH continues to emphasize improvement in health care outcomes, the methodology used by HSAG to perform compliance audits in subsequent reviews will include a more focused and targeted review of CMO data outcomes associated with the CMOs' structure and operations. This report reflects HSAG's audit results based solely on the documentation submitted by the CMOs and on-site components of the audit for the review period as required in the CMS protocol for this activity. However, in addition to HSAG expanding its focus for compliance reviews moving forward, HSAG will re-review the coordination and continuity of care standards as part of the SFY 2013 compliance review using accessory information on outcomes provided by DCH. Findings The following overall strengths were noted by HSAG across the three CMOs for each of the standards: Standard I: Availability of Services The use of an array of data from multiple sources to evaluate the adequacy of the networks and, as needed, making adjustments to ensure a sufficient mix of qualified and appropriately credentialed specialists, primary care providers, and facilities within each geographic area. Providing members direct access to specialists through standing referrals and authorization of multiple visits/services, and allowing female members direct access to a woman's health care specialist. Standard II: Furnishing of Services The documentation of performance in meeting appointment and geographic access standards by producing and analyzing reports. Monitoring the compliance of providers in meeting timely appointment and office waiting room requirements. Examining network adequacy and making adjustments as needed based on changes in populations covered and member demographics. Standard III: Cultural Competence Having policies, processes, systems, and dedicated staff members in place to ensure that the CMO promoted and delivered services in a culturally competent manner to all members. Designing and implementing company-sponsored programs and strategies to increase the cultural competency of employees, network physicians, delegated entities, and other caregivers. SFY 2012 External Quality Review Annual Report State of Georgia Page 3-3 GA2011-12_EQR_AnnRpt_F2_0612 REVIEW OF COMPLIANCE WITH STANDARDS Facilitating the reduction of health care disparities among the CMO members related to race, ethnicity, gender, age, and primary language. Standard IV: Coordination and Continuity of Care Using well-established processes and programs to identify members with special health care needs and/or members who could benefit from case management or disease management programs. Initiating discharge planning at the beginning of a clinical admission and having discharge planning procedures that include continuous evaluation of the member's needs and services to ensure a safe discharge to another level of care. Standard V: Coverage and Authorization of Services Ensuring coverage determinations are handled within appropriate timelines. Using staff skilled in utilization review and appropriate documentation of CMO coverage decisions. Standard VI: Emergency and Poststabilization Services Ensuring that members can access emergency services 24 hours a day, seven days a week to treat emergency medical conditions. Appropriately including prudent layperson language in determining the severity of presenting symptoms for members seeking emergency services and not limiting emergency medical conditions to a list of diagnoses or symptoms. CMO Comparison Key Findings HSAG highlights the following specific strengths and recommendations for each of the CMOs. AMERIGROUP Strengths Regularly monitoring, analyzing, and producing reports documenting AMERIGROUP's performance in meeting the timely appointment and geographic access standards. The CMO provided regularly required reports to DCH per the contract schedule for the deliverables, and it also provided these reports at other times when it anticipated a change or there actually had been a significant change to the network. AMERIGROUP monitored the adequacy of its network based on changes in the populations covered and member demographics, and it made adjustments as needed. Establishing that it had policies, processes, systems, and dedicated staff members in place at the corporate and local levels to ensure that the CMO promoted and delivered services in a culturally competent manner to all members. The CMO's Cultural Competency Strategic Plan Committee consisted of interdepartmental staff members dedicated to designing and implementing company-sponsored programs and strategies to increase the cultural competency SFY 2012 External Quality Review Annual Report State of Georgia Page 3-4 GA2011-12_EQR_AnnRpt_F2_0612 REVIEW OF COMPLIANCE WITH STANDARDS of AMERIGROUP employees, network physicians, delegated entities, and other caregivers. Additionally, the CMO facilitates the reduction of health care disparities among its members related to race, ethnicity, gender, age, and primary language; and facilitates improvements in accessing the highest quality care and health outcomes for its members regardless of race, ethnicity, gender, age, and primary language. From the documentation HSAG reviewed and information staff members presented during the interviews, it seemed clear that the CMO was not satisfied with only meeting the minimum standards for cultural competency, but it was also passionate about providing culturally competent services to its members. Demonstrating strong improvement in the coverage and authorization standards reviewed between Year 1 and during this review period. The CMO fully resolved 12 of the 13 areas of deficiency noted in Year 1. The CMO showed strength in its outreach and recruitment of contracted providers to participate on the CMO's medical advisory committee, fully achieving its required participation as well as selecting and retaining key providers across a broad range of specialty and geographic areas. Recommendations Ensure that it reports valid and reliable data from each of its delegated vendors related to their performance in meeting requirements for timely access and, as required by DCH, include their performance results on the quarterly timely access reports. Revise its proposed notice of action letter to include language that the member must exhaust the CMO's internal administrative review process. Ensure that policies, procedures, and process documents communicate the requirement that the CMO does not charge members for screening and treatment needed to diagnose a specific condition or to stabilize the member. Peach State Strengths Placing great emphasis on member and provider education. The CMO partnered with its vendors for outreach to noncompliant members and to educate its providers on diabetes screenings and asthma management. These efforts were designed to improve the CMO's performance measure/Healthcare Effectiveness Data and Information Set (HEDIS)3-1 rates and member outcomes. Resolving all nine previous areas of deficiency noted from the first year in the category of Coverage and Authorization of Services. The review showed that the CMO's policies and procedures were more complete and aligned with federal and DCH contract requirements. Additionally, standard operating procedures used by Peach State helped to demonstrate the application of the policies and procedures in greater detail. A review of 10 denial files showed good compliance with meeting decision time frames. The CMO appropriately identified State and federal requirements that were more stringent than NCQA requirements and had procedures in place to monitor the appropriate timelines for the CMO and its delegated entities. 3-1HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). SFY 2012 External Quality Review Annual Report State of Georgia Page 3-5 GA2011-12_EQR_AnnRpt_F2_0612 REVIEW OF COMPLIANCE WITH STANDARDS A demonstration of the utilization management system showed excellent knowledge by the utilization management staff and thorough documentation of the CMO decisions. Using data from multiple sources to evaluate the sufficiency of the provider network and, as needed, to make adjustments. The CMO considered Medicaid enrollment; utilization information; the number of providers with open and closed panels; the locations of providers compared to members; and the types of transportation to, and accessibility of, the provider offices. Showing a strong commitment to supporting its providers. Senior staff members met with providers regularly in their offices and actively engaged them in discussing what Peach State could do as a CMO to provide support and make things easier for them, and enhance their satisfaction and willingness to remain a Peach State provider. When conducting provider office visits, Peach State asked providers to complete a Post Outreach/Field Satisfaction Survey that asked if the provider was satisfied that the purpose of the visit was met, if the provider's questions were adequately answered, and what improvements Peach State could make to increase the quality of services the providers received from the CMO. Senior staff members also attended provider association meetings (e.g., Georgia Pediatric Practice Managers and the Georgia Hospital Association). Recommendations Ensure that it implements corrective actions to progressively improve its performance in meeting all DCH-required performance standards for providers achieving the timely access to appointment standards and for member geographic access to all provider types in both rural and urban areas. Ensure that its delegates revise the proposed notice of action letter to include the requirement that the member exhaust the CMO's internal administrative review process. Either revise its explanation of payment for claims denials to include all required language for a proposed notice of action or send a proposed notice of action letter with the claims denial. Address inconsistencies with Peach State's policies and procedures related to the coverage and reimbursement of poststabilization services. The CMO's Timeliness of UM Decisions and Notifications policy included information that Peach State will cover, and does not require prior authorization for poststabilization services; however, the policy also stated that certification for hospital admission or prior authorization for follow-up care is required. Additionally, interviews with CMO staff members showed that Peach State did not require precertification or prior authorization for admission to an inpatient facility after receiving emergency care. The CMO must resolve the inconsistency in all relevant documentation and train staff on the CMO's policy decisions regarding poststabilization services. WellCare of Georgia, Inc. Strengths Regularly evaluating the adequacy of the CMO's network in meeting DCH's requirements for providing timely access to appointments and for the geographic accessibility of providers by provider type, for both rural and urban areas. SFY 2012 External Quality Review Annual Report State of Georgia Page 3-6 GA2011-12_EQR_AnnRpt_F2_0612 REVIEW OF COMPLIANCE WITH STANDARDS Using robust and well-established processes and programs for identifying members with special health care needs and/or members who could benefit from either the case management or disease management programs. The CMO had a case management/disease management algorithm in place that provided a score on all active members based on several components to help identify those members in need of case or disease management. In addition to the score, members with specific chronic conditions were flagged if the condition required management. Showing an increased focus on member health outcomes that was being driven by the medical director, which aligns with DCH's quality strategy. Committee minutes contained documented discussions around opportunities to improve health outcomes as part of delegation oversight meetings. Most notable was discussion between the CMO and its delegated vision vendor to explore opportunities to improve retinal eye exam rates among members with diabetes. Recommendations Improve performance in the areas of appointment access for routine visits to a PCP within 14 calendar days, adult sick visits with a PCP within 24 hours, and nonemergency hospital stays within 30 days. WellCare fell below the 90 percent benchmark for returning after-hours calls to members within the required time frames. Additionally, WellCare did not meet all geographic access standards, primarily highly specialized providers in rural areas. WellCare should ensure that it continues to implement strategies to improve performance in meeting DCH's minimum threshold and evaluate the effectiveness of those strategies. Revise language in the member handbook which implies that members were responsible for notifying the CMO in the event of emergent, urgent, or poststabilization care. The CMO's member handbook must be revised to eliminate language suggesting that members need to notify the CMO when seeking emergent, urgent, or poststabilization care. The member handbook currently reads, Services you can get without authorization as long as the plan is notified. The CMO cannot require a member to notify the CMO in the event of emergent, urgent, or poststabilization care. Correct the statement in the member handbook regarding the explanation of urgent, emergency, and poststabilization care, which could deter members from seeking emergency care. WellCare included the following statement under the header: What to do in an Emergency: How much the plan will pay depends on the severity of your symptoms. While HSAG reviewers recognized the need to discourage emergency room overuse and abuse, the statement could discourage members from seeking care that was emergent. WellCare must revise the member handbook to remove any inference that the payment for emergency services is based on the severity of symptoms. Follow-Up Reviews of 20092010 Compliance Review Findings At the same time HSAG conducted the SFY 2012 compliance reviews, HSAG also conducted follow-up reviews to determine if the CMOs had successfully implemented required corrective actions in response to SFY 2009 and 2010 compliance review findings and recommendations. The detailed results from this follow-up review are included in Section 6. Overall, the CMOs adequately addressed most of the deficient areas; however, findings not fully resolved by the CMOs will require additional focus by the CMOs and re-review by HSAG in SFY 2013. SFY 2012 External Quality Review Annual Report State of Georgia Page 3-7 GA2011-12_EQR_AnnRpt_F2_0612 4. Performance Measures DCH annually selected performance measures to evaluate the quality of care delivered to Georgia Families members by the CMOs. The selected performance measures reflect the State's priorities and areas of concern for Georgia Families members and include a DCH-developed measure, and HEDIS and Agency for Healthcare Research and Quality (AHRQ) measures. The CMOs calculate and report data consistent with the most current reporting-year specifications. The Centers for Medicare & Medicaid Services (CMS) require that states, through their contracts with managed care plans, measure and report on performance to assess the quality and appropriateness of care and services provided to members. Validation of these performance measures is one of the three mandatory external quality review activities described at 42 CFR 438.358(b)(2). The requirement allows states, agents that are not a managed care organization, or an external quality review organization (EQRO) to conduct the performance measure validation. The purpose of performance measure validation is to ensure that managed care plans calculate performance measure rates according to state specifications. CMS also requires that states assess the extent to which the managed care plans' information systems provide accurate and complete information. During SFY 2011, the Georgia Department of Community Health (DCH) required its CMOs to report performance measure data using CY 2010 as the reporting period. Additionally, DCH contracted with Hewlett-Packard Enterprise Services (HP), its Medicaid management information system (MMIS) vendor, to calculate performance measures for the Medicaid and PeachCare for Kids Fee-for-Service (FFS) populations, Georgia Families Medicaid and PeachCare for Kids managed care populations (Georgia Families), and the total of all Medicaid and PeachCare for Kids (ALL) populations. These ALL populations measures were generated for the purposes of rate comparisons with other states and voluntary reporting of Initial Core Set metrics to CMS for the Children's Health Insurance Program Reauthorization Act (CHIPRA). All Georgia Families CMOs underwent an independent NCQA HEDIS Compliance AuditTM 4-1 by a licensed organization to ensure that the CMOs followed specifications to produce valid and reliable HEDIS measure results. HSAG received the final, audited CMO rates and ensured that the HEDIS compliance protocol met CMS' requirements for validating performance measures. Additionally, HSAG validated performance measures that were not covered under the scope of the HEDIS Compliance Audit, which consisted of measures developed by AHRQ and one DCH-developed measure. Appendix C contains a more detailed description of the method for conducting the review. Performance Measure Requirements and Targets DCH requires that CMOs collect and report performance measure rates, allowing for a standardized method to objectively evaluate the CMOs' delivery of services. DCH's requirement for the CMOs to report performance measure data annually supports the overall Georgia Families strategic plan objective: improvement and enhancement of the quality of patient care provided through ongoing, objective, and systematic measurement, analysis, and improvement of performance. 4-1 NCQA HEDIS Compliance AuditTM is a trademark of the National Committee for Quality Assurance. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-1 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES DCH adopted standardized and nationally accepted performance measures in 2009 and required the Georgia Families CMOs to use these standardized measures in their reporting of CY 2008 data to better allow for comparability among the CMOs as well as against other state and national benchmarks. Since that time, all performance measure reporting complies with standardized and nationally accepted performance measures. DCH required plans to report rates in SFY 2011 for 33 measures, reflecting the measurement period of January 1, 2010, through December 31, 2010, consisting of clinical quality measures, utilization measures, and health plan descriptive information. Many of the 33 measures include multiple components or age stratifications. DCH established performance targets for those measures and these minimum performance targets for CY 2010 data were based on the National Committee for Quality Assurance's (NCQA's) national Medicaid percentiles, with 12 of the targets being based on the 50th percentile, 10 on the 75th percentile and 8 on the 90th percentile. The CMOs' contracts were amended and approved by DCH in July 2010 to allow the CMOs to develop performance incentives for their contracted providers to drive achievement of the targets. Additionally, DCH's contracts with the CMOs provided DCH the ability to impose financial penalties for the CMOs that failed to achieve the established performance targets. The CMOs submitted their performance measure data that generally reflected the period of January 1, 2010, through December 31, 2010 in June 2011. HSAG provided final performance measure validation reports to the CMOs and DCH in July 2011. HSAG finalized the performance measure validation report for the CY 2010 HP calculated measures in March 2012. Findings Performance Measure Validation Key Findings All three DCH-contracted CMOs underwent performance measure validation for rates calculated using CY 2010 measurement period data. Strengths Beginning in 2011, DCH had HP calculate rates using the hybrid methodology when appropriate for the Georgia Families and FFS populations. The hybrid methodology uses medical record information to supplement administrative claims/encounter data to provide a more accurate reflection of performance. For the CY 2010 measurement period, HP had significant challenges procuring enough medical records to report valid rates using the hybrid methodology. Moving forward, this hybrid methodology will be valuable for quality improvement monitoring. The CMOs had fewer challenges with reporting AHRQ measures for the CY 2010 measurement period when compared with CY 2009 measurement period. All three of the CMOs were more proficient in using standardized technical specification clarifications to run rates consistently. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-2 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Challenges DCH's new MMIS vendor, HP, experienced significant delays in generating the performance measures and procuring a high percentage of medical records to report many hybrid rates. Additionally, DCH's intent was for HSAG to validate the Georgia Families and FFS hybrid rates and, if valid, combine these rates using appropriate methodology to produce the ALL population's hybrid rates for the purposes of CHIPRA reporting. During the review process, HSAG determined that there was not a valid methodology to combine these hybrid rates for the ALL population given that there was a substantial group of members in the ALL population that had not met the continuous enrollment criteria to be included in the Georgia Families or FFS populations. HSAG recommended that in subsequent years DCH consider using HSAG to combine CMO reported and audited rates to derive rates for the Georgia Families population and conduct a hybrid review of the FFS and ALL populations. HSAG was not able to validate any hybrid rates for the ALL population for the CY 2010 measurement period. In addition, many of the Georgia Families hybrid rates were given Not Reportable audit results since the procurement rate was not high enough to produce valid rates. Detailed validation results for both CMOs and HP are documented in the final audit reports. Performance Measure Result Findings Using the validated performance measure rates, HSAG organized, aggregated, and analyzed the data to draw conclusions about the CMOs' performance in providing accessible, timely, and quality care and services to Georgia Families members. Table 4-1 through Table 4-6 present the following data: CY 2009 and 2010 statewide CMO weighted averages for clinical measures from the CMOs' reported and audited data CY 2010 Georgia Families rates calculated using DCH MMIS administrative data and hybrid data when valid (validated by HSAG) CY 2010 State of Georgia FFS Medicaid data using DCH MMIS administrative data only (validated by HSAG) CY 2010 statewide CMO and FFS data to produce the ALL population using DCH MMIS administrative data only (validated by HSAG) CY 2010 performance targets for DCH-selected performance measures Similar to groupings used in the Georgia Families Quality Strategy, HSAG grouped clinical performance measures into the areas of access, children's health, women's health, diabetes care, asthma, and behavioral health to assess the overall care provided by the CMOs. HSAG used the CY 2010 CMO weighted average rates when making the comparisons to the prior-year data, the FFS data, ALL population, and the CMOs' performance targets. The CMO-reported data may reflect a more accurate assessment of care provided since the CMOs have the ability to conduct medical record reviews in addition to using administrative data for hybrid measures. Additionally, the CMOs had the opportunity to incorporate supplemental data sources, such as lab value data and immunization registry data. Appendix B contains the utilization measure results along with measures related to health plan membership information. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-3 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-1--2009/2010 Performance Measure Results--Access CY 2009 CMO Rate1 CY 2010 CMO Rate2 CY 2010 Georgia Families Rate3 CY 2010 FFS Rate4 CY 2010 ALL Population Rate CY 2010 Performance Target5 Children's and Adolescents' Access to Primary Care Providers Ages 1224 Months 96.4% 96.2% 93.8% 88.6% 93.6% Ages 25 Months6 Years 91.2% 91.1% 87.1% 83.1% 86.4% Ages 711 Years 91.3% 91.7% 89.0% 84.5% 88.1% Ages 1219 Years 88.3% 88.9% 85.1% 77.3% 83.7% 90.5% Adults' Access to Preventive/Ambulatory Health Services Ages 2044 Years 84.7% 85.1% 85.5% 73.5% 79.9% 88.8% Ages 4564 Years -- 88.9% -- -- -- Ages 65 Years and Above -- 85.7% -- -- -- Total -- 85.6% -- -- -- Oral Health (Annual Dental Visit Rate) Ages 23 Years 38.9% 43.9% 44.7% 38.2% 42.5% 41.9% Ages 46 Years 72.4% 74.4% 74.9% 62.9% 72.7% Ages 710 Years 75.2% 77.4% 77.7% 65.2% 75.5% Ages 1114 Years 67.5% 69.8% 70.1% 58.8% 67.8% Ages 1518 Years 57.2% 58.8% 59.0% 51.2% 56.8% Ages 1921 Years 37.3% 39.5% 39.9% 33.1% 35.1% All Members (Ages 221 Years) 64.1% 66.8% 67.2% 54.0% 64.2% 59.8% 1 CY 2009 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2009, through December 31, 2009. 2 CY 2010 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. Statistically significant changes between 2009 and 2010 rates are displayed where applicable. 3 CY 2010 Georgia Families rates were calculated by HP using CMO-submitted administrative data pulled from the GA MMIS. 4 CY 2010 FFS rates reflect fee-for-service claims data submitted to DCH for the measurement year, which is January 1, 2010, through December 31, 2010. 5 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. Indicates a statistically significant increase between the 2009 and 2010 weighted average rates. The 2009 rate reported in the SFY 2011 Technical Report (91.3 percent) for this measure was a typographical error. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-4 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-2--2009/2010 Performance Measure Results--Children's Health CY 2009 CMO Rate1 CY 2010 CMO Rate2 CY 2010 Georgia Families Rate3 CY 2010 FFS Rate4 CY 2010 ALL Population Rate CY 2010 Performance Target5 Well-Child/Well-Care Visits First 15 Months of Life: Six or More Visits 55.5%* 57.8%* 54.3%* 20.9% 45.1% 67.9% Third, Fourth, Fifth, and Sixth Years of Life 61.4%* 66.9%* 59.6%* 51.1% 57.7% 70.4% Adolescent Well Care 35.9%* 39.8%* 36.5%* 24.7% 32.1% 45.1% Immunization and Screening Childhood Immunization Status--Combination 3 -- 74.2%* 24.8% 16.1% 23.0% 80.6% Childhood Immunization Status--Combination 10 -- 17.3%* 4.6% 2.5% 4.1% Lead Screening in Children 66.0%* 70.3%* 54.0%* 43.5% 49.5% 80.1% Appropriate Testing for Children with Pharyngitis -- 67.8% 67.5% 64.7% 67.1% Immunizations for Adolescents-- Combination 1 Total -- 66.4% 55.8% 45.3% 52.9% Immunizations for Adolescents-- Meningococcal Total -- 69.1% 60.6% 49.2% 57.7% Immunizations for Adolescents-- Tdap/Td Total -- 80.1% 68.6% 57.4% 65.4% Weight Assessment and Counseling Body Mass Index (BMI) Percentile 30.2%* 29.6%* 1.0% 1.0% 1.0% 34.1% Counseling for Nutrition 40.4%* 48.0%* 0.5% 1.4% 0.7% 53.0% Counseling for Physical Activity 35.1%* 31.2%* 0.1% 0.1% 0.1% 39.7% Upper Respiratory Infection Appropriate Treatment for Children With Upper Respiratory 78.4% 78.5% 78.6% 77.2% 78.6% Infection 1 CY 2009 CMO rates reflect the weighted averages from the three (3) CMOs' reported and audited data for the measurement year, which is January 1, 2009, through December 31, 2009. 2 CY 2010 CMO rates reflect the weighted averages from the three (3) CMOs' reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. Statistically significant changes between 2009 and 2010 rates are displayed where applicable. 3 CY 2010 Georgia Families rates were calculated by HP using CMO-submitted administrative data pulled from the GA MMIS. 4 CY 2010 FFS rates reflect fee-for-service claims data submitted to DCH for the measurement year, which is January 1, 2010, through December 31, 2010. 5 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. *Rates are derived from the hybrid methodology in which both administrative data and medical record review data are used. Indicates a statistically significant increase between the 2009 and 2010 weighted average rates. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-5 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-3--2009/2010 Performance Measure Results--Women's Health CY 2009 CMO Rate1 CY 2010 CMO Rate2 CY 2010 Georgia Families Rate3 CY 2010 FFS Rate4 CY 2010 ALL Population Rate CY 2010 Performanc e Target5 Prevention and Screening Cervical Cancer Screening 66.7%* 71.4%* 69.1% 31.1% 45.3% 79% Breast Cancer Screening 51.1% 52.7% 53.0% 41.6% 42.5% 57.4% Chlamydia Screening--Ages 1620 Years -- 45.1% 42.1% 40.5% 44.6% Chlamydia Screening--Ages 2124 Years -- 62.8% 59.2% 38.7% 57.8% Chlamydia Screening--Total -- 49.4% 46.3% 39.8% 48.7% Prenatal Care and Birth Outcomes Timeliness of Prenatal Care 82.2%* 85.7%* 36.0% 49.0% 56.0% 89.4% Postpartum Care 66.6%* 63.2%* 40.3% 27.5% 38.9% 68.4% Cesarean Delivery Rates (AHRQ measure) 31.9% 31.6% NR NR NR Rate of Infants With Low Birth Weight (AHRQ measure) 7.5% 7.6% 8.1% 7.7% 8.0% Frequency of Ongoing Prenatal Care < 21 Percent 15.5%* 12.4%* 56.2% 45.4% 40.9% 2140 Percent 5.7%* 4.6%* 24.2% 33.4% 36.7% 4160 Percent 6.7%* 5.2%* 9.2% 11.5% 11.7% 6180 Percent 12.3%* 11.9%* 4.4% 4.9% 5.5% 81+ Percent 59.8%* 65.8%* 6.0% 4.9% 5.2% 73.4% 1 CY 2009 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2009, through December 31, 2009. 2 CY 2010 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. Statistically significant changes between 2009 and 2010 rates are displayed where applicable. 3 CY 2010 Georgia Families rates were calculated by HP using CMO-submitted administrative data pulled from the GA MMIS. 4 CY 2010 FFS rates reflect fee-for-service claims data submitted to DCH for the measurement year, which is January 1, 2010, through December 31, 2010. 5 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. *Rates are derived from the hybrid methodology in which both administrative data and medical record review data are used. Indicates a statistically significant increase between the 2009 and 2010 weighted average rates. NR--Not Reportable. The measure should not be reported because the results were not accurate using the data available. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-6 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-4--2009/2010 Performance Measure Results--Diabetes Care CY 2009 CMO Rate1 CY 2010 CMO Rate2 CY 2010 Georgia Families Rate3 CY 2010 FFS Rate4 CY 2010 ALL Population Rate CY 2010 Performance Target5 Comprehensive Diabetes Care Hemoglobin A1c (HbA1c) Testing 76.6%* 79.7%* 74.4% 45.9% 48.2% 80.7% HbA1c Poor Control (>9.0) A lower rate indicates better performance 59.3%* 54.2%* 99.9% 99.0% 99.1% 42.6% HbA1c Control (<8.0) 34.1%* 37.6%* 0.1% 0.7% 0.6% 34.8% HbA1c Control (<7.0) 29.7%*^ 28.3%* 0.1% 0.5% 0.4% 45.6% Eye Exam (retinal) Performed 40.9%* 47.1%* 40.5% 33.6% 34.0% 55.4% LDL-C Screening 66.7%* 71.3%* 64.9% 38.9% 41.0% 76.1% LCL-C Control (<100 mg/dL) 21.8%* 24.3%* 0.2% 0.9% 0.8% 35.1% Medical Attention for Nephropathy 68.7%* 71.0%* 66.3% 54.4% 55.4% 78.1% Blood Pressure Control (<140/80 mm/Hg) 24.2%* 31.1%* 0.2% 0.7% 0.7% 31.6% Blood Pressure Control (<140/90 mm/Hg) 49.9%* 53.4%* 0.3% 1.0% 0.9% 61.1% Diabetes Admission Rate Diabetes Short-Term Complications Admission Rate (per 100,000) 26.4 19.5 25.6 43.1 30.3 1 CY 2009 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2009, through December 31, 2009. 2 CY 2010 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. Statistically significant changes between 2009 and 2010 rates are displayed where applicable. 3 CY 2010 Georgia Families rates were calculated by HP using CMO-submitted administrative data pulled from the GA MMIS. 4 CY 2010 FFS rates reflect fee-for-service claims data submitted to DCH for the measurement year, which is January 1, 2010, through December 31, 2010. 5 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. * Rates are derived from the hybrid methodology in which both administrative data and medical record review data are used. ^ The CY 2009 CMO rate for this measure was calculated from two CMOs' reported and audited data since one CMO did not report a rate for this measure. Additionally, the CY 2009 CMO rate reported in the SFY 2011 Technical Report was mistakenly calculated using the eligible population for the other comprehensive diabetes care measures (757 as opposed to 667). The rate presented here reflected the correct eligible population for this measure. The CY 2009 CMO rate for this measure was based on the HEDIS 2010 specification for Blood Pressure Control (<130/80 mm/Hg). Since HEDIS 2011, this measure has changed its specification to <140/80 mm/Hg. The noted statistically significant improvement between 2009 and 2010 rates could be related to the change of the specification. Indicates a statistically significant increase between the 2009 and 2010 weighted average rates. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-7 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-5--2009/2010 Performance Measure Results--Asthma CY 2009 CMO Rate1 CY 2010 CMO Rate2 CY 2010 Georgia Families Rate3 CY 2010 FFS Rate4 CY 2010 ALL Population Rate CY 2010 Performance Target5 Use of Appropriate Medications for People With Asthma--Ages 511 Years -- 92.0% 91.8% 94.6% 91.8% Use of Appropriate Medications for People With Asthma--Ages 1250 Years -- 88.6% 88.3% 88.4% 88.1% Use of Appropriate Medications for People With Asthma--Total 90.5% 90.7% 90.5% 90.4% 90.1% 92.1% Members With ER/Urgent Care Office Visits for Asthma in the Past Six Months 1.5% 1.5% Not reported by HP Not reported by HP Not reported by HP Asthma Admission Rate (per 100,000) 104.4 100.3 50.7 415.2 350.2 1 CY 2009 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2009, through December 31, 2009. 2 CY 2010 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. Statistically significant changes between 2009 and 2010 rates are displayed where applicable. 3 CY 2010 Georgia Families rates were calculated by HP using CMO-submitted administrative data pulled from the GA MMIS. 4 CY 2010 FFS rates reflect fee-for-service claims data submitted to DCH for the measurement year, which is January 1, 2010, through December 31, 2010. 5 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-8 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-6--2009/2010 Performance Measure Results--Behavioral Health CY 2009 CMO Rate1 CY 2010 CMO Rate2 CY 2010 Georgia Families Rate3 CY 2010 FFS Rate4 CY 2010 All Population Rate CY 2010 Performance Target5 Follow-Up Care for Children Prescribed ADHD Medication Initiation Phase 43.4% 42.2% 36.9% 34.6% 36.4% 46.8% Continuation and Maintenance Phase 53.1% 54.0% 48.5% 43.9% 47.2% 53.8% Follow-Up After Hospitalization for Mental Illness Follow-Up Within 7 Days 53.2% 51.5% 44.3% 35.1% 38.3% 64.2% Follow-Up Within 30 Days 73.1% 72.7% 65.8% 57.6% 60.5% 81.2% 1 CY 2009 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2009, through December 31, 2009. 2 CY 2010 CMO rates reflect the weighted averages from the three CMOs' reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. Statistically significant changes between 2009 and 2010 rates are displayed where applicable. 3 CY 2010 Georgia Families rates were calculated by HP using CMO-submitted administrative data pulled from the GA MMIS. 4 CY 2010 FFS rates reflect fee-for-service claims data submitted to DCH for the measurement year, which is January 1, 2010, through December 31, 2010. 5 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. The 2009 rates for these two measures were different from those in the SFY 2011 Technical Report because one CMO (WellCare) resubmitted the corrected rates after the report was produced. CMO Weighted Average Performance Measure Result Findings HSAG generated the CMO weighted average performance measure rates for all CY 2010 measures. HSAG compared the CMO HEDIS measure results against the CY 2010 performance targets, which were set by DCH using national Medicaid benchmarks. Four of the CY 2010 CMO's performance targets were met, including the targets for: Annual Dental Visit for the Ages 23 Years and Ages 221 Years age stratifications; Comprehensive Diabetes Care for the HbA1c Control (<8.0) component; and Follow-Up Care for Children Prescribed ADHD Medication for the Continuation and Maintenance Phase component. Although the performance targets were not met for the remaining 28 targets, there was a statistically significant increase in performance from CY 2009 to CY 2010 in the following areas: Children's and Adolescents' Access to Primary Care Providers for the Ages 1219 Years age stratification Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents for the Counseling for Nutrition component Frequency of Ongoing Prenatal Care for the 81+ Percent component Comprehensive Diabetes Care: Eye Exam (retinal) Performed Blood Pressure Control (<140/80) SFY 2012 External Quality Review Annual Report State of Georgia Page 4-9 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES CMO Comparison Key Findings HSAG assessed CMO-specific rates for all CY 2010 required performance measures in the areas of access to care, children's health, women's health, diabetes care, asthma care, and behavioral health. Access to Care Table 4-7 displays CMO plan-specific results for access measures. Access to care measures focus on access to primary care providers for children and adolescents, access to preventive/ambulatory health services for adults, and annual dental care visits for people aged 221 years. Table 4-7--Access Domain Measures, CMO Comparison AMERIGROUP Peach State Health Plan Measure CY 2010 Rate1 CY 2010 Rate WellCare CY 2010 Rate CY 2010 Performance Target2 Children's and Adolescents' Access to Primary Care Providers Ages 1224 Months 96.8% 94.9% 96.6% Ages 25 Months6 Years 91.6% 90.7% Ages 711 Years Ages 1219 Years 92.8% 89.9% 90.6% 88.0% Adults' Access to Preventive/Ambulatory Health Services Ages 2044 Years 85.3% 84.3% 91.1% 91.9% 89.0% 85.4% 90.5% 88.8% Ages 4564 Years 90.2% 86.3% 89.6% Ages 65 Years and Above NA NA NA Total 85.9% 84.6% 86.0% Annual Dental Visit Ages 23 Years Ages 46 Years Ages 710 Years Ages 1114 Years Ages 1518 Years Ages 1921 Years 47.3% 77.0% 79.2% 71.4% 60.4% 41.4% 38.8% 72.1% 75.4% 67.1% 55.1% 35.8% 45.5% 74.6% 77.7% 70.5% 60.1% 41.0% 41.9% Total 69.1% 63.6% 67.5% 59.8% 1 CY 2010 rates reflect CMO-reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. 2 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. NA--The CMO was unable to report a rate for this measure since the denominator was too small to report a valid rate (a denominator of less than 30). AMERIGROUP performed best on measures in the area of access, followed by WellCare, then Peach State. AMERIGROUP and WellCare exceeded the CY 2010 performance target of 41.9 percent for Annual Dental Visit (Ages 23 Years), with a rate of 47.3 percent and 45.5 percent, SFY 2012 External Quality Review Annual Report State of Georgia Page 4-10 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES respectively. Peach State was just under the target, with a rate of 38.7 percent. All three CMOs achieved the CY 2010 performance target of 59.8 percent for Annual Dental Visit--Total (Ages 2 21 Years), with rates of 69.1 percent (AMERIGROUP), 63.6 percent (Peach State), and 67.5 percent (WellCare). Although AMERIGROUP met the CY 2009 performance target for Adults' Access to Preventive/Ambulatory Health Services (Ages 2044 Years), it fell short of meeting the target in CY 2010. Peach State and WellCare also did not meet the target for this measure in CY 2010. None of the CMOs met the target for Children's and Adolescents' Access to Primary Care Providers (Ages 1219 Years); however, all three were just under the goal, with rates of 89.9 percent (AMERIGROUP), 88.0 percent (Peach State), and 89.9 percent (WellCare). Findings in the area of access suggest the CMOs have adequate provider networks for Georgia Families members to access preventive care and dental visits. Findings also suggest that opportunities exist for development of strategies to increase access to preventive/ambulatory health services for adults 2044 years of age since none of the CMOs met this CY 2010 target Overall, the CMOs appear to be making progress toward meeting the performance targets, which shows the potential for increased access to services over time for Georgia Families members. Children's Health Table 4-8 displays CMO plan-specific results for children's health measures. Children's health measures focus on well-child/well-care visits, immunization and screening, weight assessment and counseling for nutrition and physical activity for children/adolescents, and appropriate treatment for children with upper respiratory infections. Table 4-8--Children's Health Domain Measures, CMO Comparison AMERIGROUP Peach State Health Plan WellCare Measure CY 2010 Rate1 CY 2010 Rate CY 2010 Rate Well-Child/Well-Care Visits First 15 Months of Life: Six or More Visits Third, Fourth, Fifth, and Sixth Years of Life Adolescent Well Care Immunization and Screening Childhood Immunization Status-- Combination 3 Childhood Immunization Status-- Combination 10 Lead Screening in Children Appropriate Testing for Children with Pharyngitis Immunizations for Adolescents-- Combination 1 Total Immunizations for Adolescents-- Meningococcal Total 60.1% 70.2% 45.6% 75.0% 18.8% 65.7% 71.8% 61.7% 64.5% 53.9% 68.5% 38.2% 77.0% 17.9% 68.5% 64.3% 70.6% 73.2% 59.1% 64.7% 38.0% 72.3% 16.5% 73.0% 67.9% NR NR 2010 Performance Target2 67.9% 70.4% 45.1% 80.6% 80.1% SFY 2012 External Quality Review Annual Report State of Georgia Page 4-11 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-8--Children's Health Domain Measures, CMO Comparison AMERIGROUP Peach State Health Plan WellCare Measure CY 2010 Rate1 CY 2010 Rate CY 2010 Rate 2010 Performance Target2 Immunizations for Adolescents-- Tdap/Td Total 77.5% 82.4% NR Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents BMI Percentile (Total) 28.5% 29.0% 30.4% 34.1% Counseling for Nutrition (Total) 48.8% 45.5% 48.9% 53.0% Counseling for Physical Activity (Total) 30.9% 32.0% 30.9% 39.7% Upper Respiratory Infection (URI) Appropriate Treatment for Children With URI 80.4% 79.0% 77.5% 1 CY 2010 rates reflect CMO-reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. 2 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. In the children's health domain, DCH selected eight CY 2010 performance targets, and only one target was achieved by one CMO, AMERIGROUP, which met the CY 2010 performance target of 45.1 percent for the Adolescent Well Care measure with a rate of 45.6 percent. Peach State and WellCare had rates of 38.2 percent and 38.0 percent, respectively, for this measure. Although it did not meet the CY 2010 performance target of 70.4 percent for Well-Child Visits--Third, Fourth, Fifth, and Sixth Years of Life, AMERIGROUP was just under this target with a rate of 70.2 percent. AMERIGROUP and WellCare achieved the CY 2009 performance target of 72.0 percent for childhood immunizations; however, both fell short of the CY 2010 performance target of 80.6 percent, with rates of 75.0 percent and 77.0 percent, respectively. These two plans also met the CY 2009 performance target for Lead Screening in Children but did not meet the CY 2010 target. Overall, AMERIGROUP performed best on six of the rates, Peach State performed best on five rates, and WellCare performed best on three. It should be noted that WellCare did not report any data for the Immunizations for Adolescents measure. Many opportunities exist for improvement strategies to be developed since two CMOs fell short of all eight CY 2010 performance targets and one fell short of seven of the targets. Women's Health Table 4-9 displays CMO plan-specific results for the women's health measures. Women's health measures focus on prevention and screening, prenatal care and birth outcomes, and frequency of ongoing prenatal care. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-12 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-9--Women's Health Domain Measures, CMO Comparison AMERIGROUP Peach State Health Plan WellCare Measure CY 2010 Rate1 CY 2010 Rate CY 2010 Rate 2010 Performance Target2 Prevention and Screening Cervical Cancer Screening 70.3% 68.9% 73.2% 79.0% Breast Cancer Screening 53.0% 51.4% 53.4% 57.4% Chlamydia Screening--Ages 1620 Years 43.9% 47.8% 44.2% Chlamydia Screening--Ages 2124 Years 60.8% 66.3% 61.6% Chlamydia Screening--Total 47.5% 52.6% 48.5% Prenatal Care and Birth Outcomes Timeliness of Prenatal Care 90.5% 83.0% 84.7% 89.4% Postpartum Care 65.7% 60.7% 63.3% 68.4% Cesarean Delivery Rate 32.9% 31.4% 31.1% Rate of Infants With Low Birth Weight 7.8% 7.5% 7.5% Frequency of Ongoing Prenatal Care < 21 Percent 6.0% 12.1% 16.1% 2140 Percent 4.2% 5.8% 4.1% 4160 Percent 6.0% 6.3% 4.1% 6180 Percent 11.1% 11.4% 12.7% 81+ Percent 72.6% 64.4% 63.0% 73.4% 1 CY 2010 rates reflect CMO-reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. 2 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. WellCare outperformed AMERIGROUP and Peach State on the breast and cervical cancer screening measures. This is a change from CY 2009 when AMERIGROUP outperformed the other two CMOs on these measures. WellCare had the highest rate for Postpartum Care in CY 2009; but in CY 2010, AMERIGROUP had the highest rate at 65.7 percent. Peach State and WellCare's rates for this measure in CY 2010 were 60.7 percent and 63.3 percent, respectively. Peach State outperformed AMERIGROUP and WellCare on the chlamydia screening measure. AMERIGROUP outperformed Peach State and WellCare on the Frequency of Ongoing Prenatal Care measure for the 81+ Percent component and was just under the CY 2010 performance target of 73.4 percent, with a rate of 72.6 percent. In CY 2009, Peach State had the highest rate for Timeliness of Prenatal Care; however, in CY 2010, AMERIGROUP had the highest rate at 90.5 percent. AMERIGROUP achieved the CY 2010 performance target rate of 89.4 percent on this measure but did not achieve any other CY 2010 performance target rates in the women's health domain. Peach State and WellCare did not achieve any of the CY 2010 performance targets in the women's health domain. The CMOs have many opportunities for improvement on their performance related to the women's health measures. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-13 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Diabetes Care Table 4-10 displays CMO plan-specific results for diabetes health measures. Diabetes health measures focus on comprehensive diabetes care and diabetes admission rates. Table 4-10--Physical Health Conditions: Diabetes Health Domain Measures, CMO Comparison AMERIGROUP Peach State Health Plan WellCare Measure CY 2010 Rate1 CY 2010 Rate CY 2010 Rate CY 2010 Performance Target2 Comprehensive Diabetes Care HbA1c Testing 81.9% 72.6% 82.3% 80.7% HbA1c Poor Control (>9.0) A lower rate indicates better performance 52.5% 60.1% 52.0% 42.6% HbA1c Good Control <8.0 38.2% 33.8% 39.2% 34.8% HbA1c Good Control <7.0 29.9% 24.2% 29.7% 45.6% Eye Exam 47.1% 46.0% 47.6% 55.4% LDL-C Screening 70.7% 65.0% 74.8% 76.1% LDL-C Level 28.5% 19.7% 24.6% 35.1% Medical Attention for Nephropathy 70.9% 70.1% 71.5% 78.1% Blood Pressure Control < 140/80 Blood Pressure Control < 140/90 33.7% 56.0% 24.1% 43.9% 33.4% 56.9% 31.6% 61.1% Diabetes Admission Rate Diabetes Short-Term Complications Admission Rate (per 100,000) 16.1 20.9 19.9 1 CY 2010 rates reflect CMO-reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. 2 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. All the CMO CY 2009 rates were below the CY 2009 performance target of 79.0 percent for HbA1c testing; however, AMERIGROUP and WellCare achieved the CY 2010 performance target of 80.7 percent for this measure, with rates of 81.8 percent and 82.3 percent, respectively. Peach State's rate for this measure was 72.6 percent. AMERIGROUP and WellCare met the CY 2010 performance target of 34.8 percent for Comprehensive Diabetes Care--HbA1c Good Control (<8.0), with rates of 38.2 percent and 39.2 percent, respectively. Peach State had a rate of 33.8 percent on this measure. AMERIGROUP and WellCare also met the CY 2010 performance target of 31.6 percent for Comprehensive Diabetes Care--Blood Pressure Control (<140/80), with rates of 33.7 percent and 33.4 percent, respectively. Peach State had a rate of 24.1 percent on this measure. Overall, WellCare performed best compared with AMERIGROUP and Peach State in CY 2009 and continued to do so in CY 2010. Peach State appears to have the most opportunities for improvement in its performance related to diabetes care based on the findings. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-14 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Asthma Care Table 4-11 displays CMO plan-specific results for asthma measures. Asthma measures focus on use of appropriate medications, emergency department/urgent care visits, and admission rates. Table 4-11--Physical Health Conditions: Asthma Domain Measures, CMO Comparison Measure AMERIGROUP CY 2010 Rate1 Peach State Health Plan CY 2010 Rate WellCare CY 2010 Rate CY 2010 Performance Target2 Use of Appropriate Medications for People With Asthma--511 Years Use of Appropriate Medications for People With Asthma--1250 Years Use of Appropriate Medications for People With Asthma--Total Percent of Members Who Have Had a Visit to an Emergency Department/Urgent Care Office for Asthma in the Past Six Months 92.3% 89.7% 91.3% 2.2% 91.1% 87.5% 89.8% 1.3% 92.5% 88.7% 91.1% 1.3% 92.1% Asthma Admission Rate (per 100,000) 76.7 114.0 101.3 1 CY 2010 rates reflect CMO-reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. 2 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. AMERIGROUP performed best on three of the measures in CY 2010 when compared with Peach State and WellCare. Peach State and WellCare outperformed AMERIGROUP on the Percent of Members Who Have Had a Visit to an Emergency Department/Urgent Care Office for Asthma in the Past Six Months measure. Both had a rate of 1.3 percent compared to AMERIGROUP's rate of 2.2 percent. There was only one measure with a CY 2010 performance target (Use of Appropriate Medications for People With Asthma--Total). None of the CMOs met the performance target of 92.1 percent; however, AMERIGROUP and WellCare were just below it, with rates of 91.3 percent and 91.1 percent, respectively. Peach State had a rate of 89.8 percent on this measure. AMERIGROUP's Asthma Admission Rate (per 100,000) rate was well below the rates of Peach State and WellCare, with a rate of 76.7 compared to 114.0 (Peach State) and 101.3 (WellCare). The findings show that the CMOs appear to be doing a good job providing the appropriate medications for persons with asthma, and the care being provided may be impacting the overall low percentage of members visiting the emergency department/urgent care office for their asthma. Behavioral Health Table 4-12 displays CMO plan-specific results for behavioral health measures. Behavioral health measures focus on follow-up care for children prescribed ADHD medication and follow-up after hospitalization for mental illness. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-15 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Table 4-12--Behavioral Health Domain Measures, CMO Comparison Measure AMERIGROUP CY 2010 Rate1 Peach State Health Plan CY 2010 Rate WellCare CY 2010 Performance CY 2010 Rate Target2 Follow-Up Care for Children Prescribed ADHD Medication Initiation Phase 45.6% 41.9% 41.3% 46.8% Continuation and Maintenance Phase 58.4% 56.0% 52.1% 53.8% Follow-Up After Hospitalization for Mental Illness Follow-Up Within 7 Days 46.6% 52.7% 54.0% 64.2% Follow-Up Within 30 Days 70.9% 72.8% 73.8% 81.2% 1 CY 2010 rates reflect CMO-reported and audited data for the measurement year, which is January 1, 2010, through December 31, 2010. 2 CY 2010 performance targets reflect the DCH-established CMO performance targets for 2010. Shaded boxes are displayed when no DCH CY 2010 performance target was established. AMERIGROUP outperformed Peach State and WellCare on the Follow-Up Care for Children Prescribed ADHD Medication measures and both AMERIGROUP and Peach State achieved the CY 2010 performance target of 53.8 percent for the Continuation and Maintenance Phase measure, with rates of 58.4 percent and 56.0 percent, respectively. WellCare performed just below the target, with a rate of 52.1 percent. WellCare continued to outperform AMERIGROUP and Peach State on the Follow-Up After Hospitalization for Mental Illness measure. None of the CMOs met the CY 2010 performance targets for the Follow-Up Care for Children Prescribed ADHD Medication-- Initiation Phase component or the Follow-Up After Hospitalization for Mental Illness measure. Findings suggest that all CMOs have the opportunity to make improvements to their follow-up processes. Fee-For-Service and ALL Population Comparisons In addition to comparing CMO weighted average performance to national benchmarks and targets, HSAG compared the CMOs' performance to the Medicaid FFS population and ALL population. While HSAG assessed the rates of the CMOs' weighted averages, comparisons with the FFS and ALL populations should be made with caution. CMO-reported data may reflect a more accurate assessment of care provided since the CMOs had the ability to conduct medical record reviews in addition to using administrative data for hybrid measures. Additionally, the CMOs may have used supplemental data sources such as lab value data and immunization registries to increase data capture. FFS and ALL rates were calculated using only claims data, which may not be as accurate as the CMO-reported data that includes the medical record reviews, lab data, and registry data. Performance measure results showed that the CMOs had better performance than the Medicaid FFS and ALL populations when comparing the overall CMO weighted averages to FFS and ALL data on nearly all measures. In CY 2009, the FFS and CMO programs had the same rate for Use of Appropriate Medications for People With Asthma; however, in CY 2010, the FFS program outperformed the CMOs on the Use of Appropriate Medications for People With Asthma measure for the Ages 511 Years component, with a rate of 94.6 percent compared to the CMO rate of 92.0 percent. The CMOs had a higher rate on the Use of Appropriate Medications for People With SFY 2012 External Quality Review Annual Report State of Georgia Page 4-16 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Asthma--Total measure, with a rate of 90.7 percent; and the FFS program's rate on this measure was 90.4 percent. In CY 2009 the FFS program outperformed the CMOs on the Follow-Up Care for Children Prescribed ADHD Medication measure; however, in CY 2010, the CMOs outperformed the FFS program on this measure. The findings suggest that CMO members received higher quality care, had better access to services, and received more timely care than FFS members. Utilization Measures In addition to clinical performance measures, DCH required the CMOs to report utilization rates for inpatient utilization, mental health utilization, antibiotic utilization and outpatient drug utilization. Utilization information can be helpful to the CMOs in reviewing patterns of suspected under- and overutilization of services. High or low rates of utilization do not necessarily indicate better or worse performance. Appendix B contains a table of utilization measures by CMO and an overall CMO weighted average rate for each measure. The CMOs should use these comparisons to further analyze utilization patterns for potential problem areas related to provider practice patterns, geographic accessibility, etc. Some utilization rates, such as maternity and inpatient discharges, do not indicate a need to evaluate performance; rather, they simply provide the CMOs and DCH with information on the CMOs' rates and allow them to be compared to national rates. Health Plan Demographics The CMOs reported health plan demographic information for Race/Ethnicity of Membership, Language Diversity of Membership and Weeks of Pregnancy at Time of Enrollment. Appendix B contains the CMOs' rates for these measures. The data showed that 46.5 percent of Georgia Medicaid managed care members were Black, 43.2 percent were White, 1.9 percent were Asian, 5.0 percent were Hispanic or Latino, and 6.5 percent were categorized as unknown. Ethnicity data were not captured completely, as 68.5 percent showed an unknown ethnicity; however, the data capture has improved from CY 2009, which showed 93.4 percent as unknown ethnicity. Nearly 90 percent of Georgia Families members spoke English, approximately 8 percent were non-English speaking, and 2 percent unknown. The data also showed that 59.9 percent of Georgia Medicaid managed care members who were pregnant were enrolled in the program between 13 and 27 weeks of pregnancy. A contributing factor to this rate is the fact that Georgia Medicaid-eligible managed care members are first enrolled into FFS Medicaid and then must select a CMO. This selection process may take up to 60 days, thus giving the appearance in this measure that some pregnant members are without health care coverage until their second trimester when in fact they are able to access prenatal care services as soon as they become eligible for Medicaid. Health plan demographic information may be useful to DCH and the CMOs when considering targeted interventions to ensure that strategies are appropriate for the targeted populations and culturally and linguistically appropriate services are available to members. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-17 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Conclusions HSAG found that all the CMOs were compliant with the required information system standards to report valid performance measure rates. Overall, the CMOs demonstrated the ability to process, receive, and enter medical and service data efficiently, accurately, timely and completely. The CMOs demonstrated greater proficiency with reporting the AHRQ measures. Overall, of the 32 CY 2010 performance targets, the CMOs performed best in the area of oral health, achieving the CY 2010 performance targets for both the 23 years of age stratification rate and the total member rate. When comparing measures with both CY 2009 and CY 2010 rates, the CMO weighted average rates showed statistically significant improvement in the following five areas: Children's and Adolescents' Access to Primary Care Providers Ages 1219 Years Annual Dental Visit Ages 23 Years Ages 221 Years Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Counseling for Nutrition Frequency of Ongoing Prenatal Care 81+ Percent Comprehensive Diabetes Care Eye Exam (retinal) Performed Blood Pressure Control (<140/80) Many opportunities for improvement exist for the CMOs as a whole. One area with opportunity for improvement is behavioral health. The CMOs' weighted averages for three of the four behavioral health components decreased from CY 2009 to CY 2010, and only one CY 2010 behavioral health performance target was met (Follow-Up Care for Children Prescribed ADHD Medication for the Continuation and Maintenance Phase component). The CMOs also have room for improvement in the areas of children's health, women's health, and asthma--all areas where none of the CY 2010 performance targets were met. Although one CY 2010 performance target was met and statistically significant improvement was shown for two components in the area of Comprehensive Diabetes Care, there is opportunity for improvement since the CMOs as a whole did not achieve 9 of the 10 CY 2010 diabetes performance targets. This finding is disturbing given that all CMOs have a diabetes disease management program and case management programs. HSAG will further explore the disease management and case management programs in SFY 2013 to help identify the underlying disconnect(s) and provide more specific feedback to the CMOs and DCH regarding recommendations for improvement in this area. The findings show that the CMOs, as a whole, performed best in the area of access. Two of the four CY 2010 access performance targets were met, and there was statistically significant improvement on one of the rates that did not meet the CY 2010 performance target. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-18 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES Based on CY 2010 CMO performance, AMERIGROUP was the highest overall performer compared with Peach State and WellCare. It outperformed Peach State and WellCare in the following areas: Children's and Adolescents' Access to Primary Care Providers Annual Dental Visit Well-Child Visits Adolescent Well Care Appropriate Testing for Children with Pharyngitis Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Appropriate Treatment for Children With Upper Respiratory Infection Timeliness of Prenatal and Postpartum Care Frequency of Ongoing Prenatal Care Diabetes Short-Term Complications Admission Rate Use of Appropriate Medications for People With Asthma AMERIGROUP met eight of the CY 2010 performance targets, followed by WellCare, which met five of the targets, and Peach State, which met two of the targets. Peach State demonstrated higher performance than AMERIGROUP in the area of Immunizations for Adolescents (no data were reported by WellCare for these measures), and WellCare demonstrated the highest performance in the area of Comprehensive Diabetes Care. Although Peach State made some improvements in performance from CY 2009, it remains the CMO with the greatest opportunity for improvement, especially in the areas of access, diabetes, and prenatal care. AMERIGROUP's greatest opportunities for improvement are in the areas of adolescent immunizations, chlamydia screening, and diabetes care. WellCare's greatest opportunities for improvement are in the areas of access, children's health, and chlamydia screening. All CMOs have the opportunity to make improvements related to meeting performance targets in all domains. Recommendations Based on the CY 2010 performance measure rates and validation of those rates, HSAG provides the following recommendations for improving the quality, timeliness of, and access to care and services for members: DCH should continue to require the CMOs to report on the same set of performance measures for CY 2011 to allow for year-to-year comparisons and trending over time to determine if the CMOs are improving the delivery of quality care to Georgia Families members. DCH and the CMOs should determine what strategies contributed to high performance measure rates and evaluate whether these strategies can be applied to areas of low performance. DCH may want to consider measures with low performance for the auto-assignment program as a mechanism to drive improvement. The CMOs should consider collaborating with other CMOs that have a common area of low performance as part of a formal quality improvement process. This has been an effective SFY 2012 External Quality Review Annual Report State of Georgia Page 4-19 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE MEASURES strategy for many managed care organizations in improving performance measure rates, especially when there is significant overlap of provider networks within a geographic area. DCH should evaluate PIP topics and prioritize areas of low performance for future statewide collaborative efforts. AMERIGROUP needs to focus quality improvement efforts in the areas of diabetes care and prenatal and postpartum care by conducting a causal/barrier analysis; evaluating existing strategies; and developing new, targeted strategies that address the identified barriers. Peach State and WellCare need to focus quality improvement efforts in the areas of diabetes care and well-care visits by conducting a causal/barrier analysis; evaluating existing strategies; and developing new, targeted strategies that address the identified barriers. SFY 2012 External Quality Review Annual Report State of Georgia Page 4-20 GA2011-12_EQR_AnnRpt_F2_0612 5. Performance Improvement Projects The purpose of a performance improvement project (PIP) is to achieve, through ongoing measurements and interventions, significant improvement sustained over time in both clinical and nonclinical areas. HSAG reviewed each PIP using CMS' validation protocol to ensure that the CMOs designed, conducted, and reported the PIPs in a methodologically sound manner and met all State and federal requirements. The validation was to ensure that DCH and interested parties could have confidence in the reported improvements that resulted from the PIPs. The CMOs each had nine DCH-selected PIP topic areas in progress during the review period. Seven topic areas were clinical areas of focus and included the following HEDIS measures: Adults' Access to Preventive/Ambulatory Health Services--2044 Years of Age Annual Dental Visit Childhood Immunization Status--Combination 2 Childhood Obesity Emergency Room Utilization Lead Screening in Children Well-Child Visits in the First 15 Months of Life--Six or More Visits In addition, two nonclinical PIP topics were selected by DCH for the CMOs in the areas of member satisfaction and provider satisfaction. Validating PIPs is one of three federally mandated external quality review activities. The requirement allows states, agents that are not a managed care organization, or an EQRO to conduct the PIP validations. DCH contracted with HSAG to conduct the functions associated with validation of PIPs. Validation of Performance Improvement Projects HSAG organized, aggregated, and analyzed the three CMOs' PIP data to draw conclusions about the CMOs' quality improvement efforts in the areas of quality, access, and timeliness. The PIP validation process evaluated both the technical methods of the PIP (i.e., the study design) and the performance measure outcomes associated with the implementation of interventions. Based on its technical review, HSAG determined the overall methodological validity of the PIPs. Appendix C provides additional detail on the methodology HSAG used for validating the PIPs. In addition to the current scoring methodology, HSAG worked with DCH to modify the existing PIP validation scoring methodology to ensure that the CMOs achieve improvement in the study outcomes for all PIPs submitted for validation in the future. These modifications will add emphasis to achieving improved study indicator outcomes while keeping the number of evaluation elements the same. The new PIP Validation Tool (new tool) is identical to the current PIP Validation Tool (current tool) for Activities I through VII. In Activity VIII (sufficient data analysis and interpretation), the CMOs must present study results that are accurate, clear, and easily understood. SFY 2012 External Quality Review Annual Report State of Georgia Page 5-1 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE IMPROVEMENT PROJECTS Sufficient data analysis and interpretation is now a critical element; therefore, if the study indicator results are not accurate, the PIP cannot receive an overall Met validation status. In Activity IX (real improvement achieved), the CMOs must achieve statistically significant improvement for the study indicator outcomes between the baseline and remeasurement period. Real improvement achieved will now be a critical element for all PIPs that progress to this stage; therefore, any PIP that does not achieve statistically significant improvement will not receive an overall Met validation status. For Activity X (sustained improvement achieved), HSAG assesses each study indicator for sustained improvement after the PIP indicator achieves statistically significant improvement. For PIPs with multiple indicators, all indicators that can be assessed must achieve sustained improvement to receive a Met score for Activity X. The new validation scoring methodology will be applied to the PIPs that the CMOs will submit for validation between June 2012 and August 2012. In preparation for this change, during FY 2012 HSAG first scored the PIPs using the current tool, then with the new tool. The scores included in this report were calculated using the current tool. Scores using the new tool were provided for informational purposes only and reflect the validation scores the CMOs would receive if HSAG validated the PIP using the modified validation scoring methodology described above. Table 5-1 displays aggregate CMO validation results for all PIPs evaluated between June 2011 and August 2011. The CMOs submitted PIP data that reflected varying time periods, depending on the PIP topic. HSAG provided final, CMO-specific PIP reports to the CMOs and DCH in October 2011. This table illustrates the CMOs' overall understanding of the PIP process for the studies' Design, Implementation and Outcomes phases. Each activity is composed of individual evaluation elements scored as Met, Partially Met, or Not Met. Elements receiving a Met score have satisfied the necessary technical requirements for a specific element. The percentage of applicable evaluation elements that received Met scores using both the current tool and the new tool are included in the table. Appendix C, Tables C2, C5, and C8 provide the CMO-specific validation scores. Table 5-1--SFY 2011 Performance Improvement Projects' Validation Results for Georgia Families (N=27 PIPs) Study Stage Activity Percentage of Applicable Elements Scored Met Current Tool New Tool Design I. Appropriate Study Topic II. Clearly Defined, Answerable Study Question(s) III. Clearly Defined Study Indicator(s) IV. Correctly Identified Study Population 99% (149/150) 100% (54/54) 96% (155/162) 100% (78/78) 99% (149/150) 100% (54/54) 96% (155/162) 100% (78/78) SFY 2012 External Quality Review Annual Report State of Georgia Page 5-2 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE IMPROVEMENT PROJECTS Table 5-1--SFY 2011 Performance Improvement Projects' Validation Results for Georgia Families (N=27 PIPs) Design Total 98% (436/444) 98% (436/444) V. Valid Sampling Techniques (if sampling was used) 100% (108/108) 100% (108/108) Implementation VI. Accurate/Complete Data Collection 100% (213/214) 100% (213/214) VII. Appropriate Improvement Strategies 99% (103/104) 99% (103/104) Implementation Total 100% (424/426) 100% (424/426) VIII. Sufficient Data Analysis and Interpretation 94% (221/234) 94% (221/234) Outcomes IX. Real Improvement Achieved 64% (69/108) 65% (70/108) X. Sustained Improvement Achieved 85% (11/13) 86% (6/7) Outcomes Total 85% (301/355) 85% (297/349) Overall Percentage of Applicable Evaluation Elements Scored Met 95% (1161/1225) 95% (1157/1219) 1 The current tool was used to score the CMO for the PIPs submitted in SFY 2011 and validated in SFY 2012. 2 The new tool incorporated the revised scoring methodology for Activities VIII through X and will be used to validate the CMOs' SFY 2012 PIPs and is provided for informational purposes only. Those validations will occur during SFY 2013. Of the 27 PIPs evaluated for real improvement, 13 PIPs were evaluated for sustained improvement using the current tool. Only seven of the 13 PIPs could be evaluated for sustained improvement using the new tool. For the new tool, the CMO must first achieve statistically significant improvement in order to be evaluated for sustained improvement in a subsequent remeasurement period. Findings Performance Improvement Project Validation Key Findings The overall aggregated validation results for the Design total during the review period demonstrated the CMOs' proficiency and thorough application of the Design stage. The sound design of the PIPs created a foundation for the CMOs to progress to subsequent PIP stages--i.e., implementing improvement strategies and accurately assessing and achieving study outcomes. The Implementation stage results demonstrated that the CMOs accurately documented and executed the application of the study design, and then successfully identified, developed, and implemented interventions. With the successful implementation of appropriate improvement strategies, the CMOs should be able to achieve improved outcomes in the future. The overall percentage score decrease for the Outcomes total was attributed to the individual scores of AMERIGROUP and WellCare, which were lower than the score for Peach State. In the SFY 2012 External Quality Review Annual Report State of Georgia Page 5-3 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE IMPROVEMENT PROJECTS Outcomes stage, HSAG assessed for statistically significant improvement between the most recent remeasurement years for PIPs that had at least one remeasurement period using the current tool. Forty-eight percent of these PIPs (13 out of 27 PIPs) had at least one study indicator that demonstrated statistically significant improvement during the review period. Using the new tool, 70 percent of PIPs (19 out of 27 PIPs) had at least one study indicator that demonstrated statistically significant improvement between any two measurement periods. Using the current tool, 13 PIPs progressed to a second remeasurement period which HSAG assessed for sustained improvement. Eleven of the PIPs achieved sustained improvement. Using the new tool, only seven PIPs had achieved statistically significant improvement with a subsequent remeasurement period that could be used to assess sustained improvement. Of those seven PIPs, six achieved sustained improvement. CMO Comparison Key Findings Table 5-2 displays the CMOs' validation results by study stage for all nine PIPs conducted by each of the three CMOs and evaluated during the review period. Table 5-2--SFY 2011 Performance Improvement Project Validation Results Comparison by CMO (N=27 PIPs) Percentage of Applicable Elements Scored Met Study Stage Activities AMERIGROUP Current Tool New Tool Peach State Current Tool New Tool WellCare Current Tool New Tool Design Implementation Outcomes Activities IIV Activities VVII Activities VIIIX 99% 99% 100% 100% 95% 95% (146/147) (146/147) (148/148) (148/148) (142/149) (142/149) 100% 100% 100% 100% 99% 99% (142/142) (142/142) (143/143) (143/143) (139/141) (139/141) 84% 82% 88% 90% 82% 84% (97/116) (95/116) (106/120) (105/117) (98/119) (97/116) Overall Percentage of Applicable Evaluation Elements Scored Met 95% 95% 97% 97% 93% 93% (385/405) (383/405) (397/411) (396/408) (379/409) (378/406) All three CMOs met over 95 percent of the requirements across all nine PIPs for all four activities within the Design stage. AMERIGROUP did not include one of the two mandatory study indicators for the Childhood Obesity PIP, which reduced its score in this study stage. WellCare did not properly define its study indicators in its Childhood Obesity PIP and its Annual Dental Visit PIP according to HEDIS methodology, which also reduced its score for this stage. Overall, the CMOs designed scientifically sound studies that were supported by the use of key research principles. The technical design of each PIP was sufficient to measure and monitor PIP outcomes associated with the CMOs' improvement strategies. The solid design of the PIPs allowed the successful progression to the next stage of the PIP process. All three CMOs demonstrated an even stronger application of intervention strategies. With the successful implementation of appropriate improvement strategies, the CMOs should be able to achieve and sustain improved outcomes in the future. SFY 2012 External Quality Review Annual Report State of Georgia Page 5-4 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE IMPROVEMENT PROJECTS All three CMOs scored lower for the Outcomes stage since not all of the study indicators demonstrated statistically significant improvement. Additionally, AMERIGROUP was scored lower since it did not report outcomes for one of the Childhood Obesity study indicators. Many of the improvement strategies implemented by the CMOs will continue to improve the study outcomes as time progresses. Outcome Results Table 5-3 and Table 5-4 display the outcomes data for the CMOs' clinical PIPs. For these HEDISbased PIPs, each CMO used the same study indicator(s), which allowed HSAG to compare results across the CMOs. Detailed study indicator descriptions as well as rates for each measurement period are provided in Appendix C, Tables C3, C4, C6, C7, C9, and C10. In Table 5-3, HSAG displays the CY 2010 rate and whether there was statistically significant improvement compared to the CY 2009 rate. Additionally, studies with a second remeasurement period were assessed for sustained improvement using both the current tool and the new tool. Table 5-3--HEDIS-based Performance Improvement Project Outcomes (validated during SFY 2012) Comparison by CMO AMERIGROUP Peach State WellCare PIP Topic Remeasurement 2 Period 1/1/10 12/31/10 Sustained Improvement Current New Tool Tool Remeasurement 2 Period 1/1/10 12/31/10 Sustained Improvement Current New Tool Tool Remeasurement 2 Period 1/1/10 12/31/10 Sustained Improvement Current New Tool Tool Adults' Access to Preventive/ Ambulatory Health Services--2044 Years of Age 85.3%A Yes Yes 84.3% Yes Yes 85.4% * Yes Yes Childhood Immunization Status--Combination 78.0% * Yes Yes 81.4% * Yes 2 75.9% No Lead Screening in Children 65.7% 68.5% Yes 73.0% Yes Well-Child Visits in the First 15 Months of Life--Six or More Visits 60.1% 53.9% Yes 59.1% SFY 2012 External Quality Review Annual Report State of Georgia Page 5-5 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE IMPROVEMENT PROJECTS Table 5-3--HEDIS-based Performance Improvement Project Outcomes (validated during SFY 2012) Comparison by CMO AMERIGROUP Peach State WellCare PIP Topic Remeasurement 1 Period 1/1/10 12/31/10 Sustained Improvement Current New Tool Tool Remeasurement 1 Period 1/1/10 12/31/10 Sustained Improvement Current New Tool Tool Remeasurement 1 Period 1/1/10 12/31/10 Sustained Improvement Current New Tool Tool Annual Dental Visit-- 23 Years of NR Age 38.8% * 45.5% * Annual Dental Visit-- 221 Years of 69.1% * 63.6% * 67.5% * Age Childhood Obesity-- BMI Documentation 28.5% * 29.0% 30.4% Childhood Obesity-- Counseling for 48.8% * 45.5% * 48.9% Nutrition Childhood Obesity-- Counseling for 30.9% A 32.0% Physical Activity 30.9% * Emergency Room Utilization per 1,000 58.1% * 54.7% * 61.7% * Member Months A Rates differed slightly from those reported by the CMO in its PIP. The PIP did not include Remeasurement 1 results and could not be assessed for real or sustained improvement, or the PIP did not report Remeasurement 2 results and could not be assessed for sustained improvement. Improvement over baseline must occur before sustained improvement can be assessed using the current tool. Using the new tool, statistically significant improvement over baseline must occur before sustained improvement can be assessed. A subsequent measurement period is required before sustained improvement can be assessed. * Designates statistically significant improvement over the prior measurement period (p value < 0.05). * Designates statistically significant decline in performance over the prior measurement period (p value < 0.05). ^ Sustained improvement is defined as improvement in performance over baseline which is maintained or increased for at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect improvement when compared to the baseline results. Sustained improvement in the new tool is defined as statistically significant improvement in performance over baseline which is maintained or increased for at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect statistically significant improvement when compared to the baseline results. NR The CMO did not report the DCH-mandated study indicator results. Only WellCare demonstrated statistically significant improvement for the Adults' Access to Care PIP. AMERIGROUP and Peach State showed statistically significant improvement for the Childhood Immunizations PIP. For the satisfaction-based PIPs, each CMO selected different study indicators; therefore, comparisons across the CMOs could not be made. The results are presented as the number of study indicators only instead of specific study indicator rates. SFY 2012 External Quality Review Annual Report State of Georgia Page 5-6 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE IMPROVEMENT PROJECTS Table 5-4--SFY 2011 Satisfaction-Based Performance Improvement Project Outcomes Comparison by CMO PIP Topic1 (Number of Study Indicators) Comparison to Study Indicator Results from Prior Measurement Period Statistically Significant Improvement Non-Statistically Significant Change Statistically Significant Decline Sustained Improvement Current Tool^ New Tool AMERIGROUP Member Satisfaction (N=2) 1 1 0 , , Provider Satisfaction* (N=1) 0 1 0 Peach State Member Satisfaction 1 3 0 Yes No, , (N=4) Provider Satisfaction 0 4 0 Yes Yes (N=4) WellCare Member Satisfaction 0 2 0 No, (N=2) Provider Satisfaction 1 2 0 Yes Yes, (N=3) 1 The number of study indicators varied per PIP topic conducted by each of the three CMOs. * AMERIGROUP modified the study methodology and established a new baseline; therefore, only Remeasurement 1 data were submitted for validation and sustained improvement could not be assessed. Improvement over baseline must occur before sustained improvement can be assessed using the current tool. Using the new tool, statistically significant improvement over baseline must occur before sustained improvement can be assessed. A subsequent measurement period is required before sustained improvement can be assessed. The PIP did not progress to the phase where sustained improvement could be assessed. ^ Sustained improvement in the current tool is defined as improvement in performance over baseline which is maintained or increased for at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect improvement when compared to the baseline results. Sustained improvement in the new tool is defined as statistically significant improvement in performance over baseline which is maintained or increased for at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect statistically significant improvement when compared to the baseline results. AMERIGROUP and Peach State both demonstrated statistically significant improvement for one of their Member Satisfaction PIP study indicators. WellCare demonstrated statistically significant improvement for one of its Provider Satisfaction PIP study indicators. Using the current tool, Peach State reported sustained improvement for all of its Provider Satisfaction and Member Satisfaction study indicators. WellCare demonstrated sustained improvement for all of its Provider Satisfaction study indicators. Using the new tool, Peach State still achieved sustained improvement for all of its Provider Satisfaction study indicators; and WellCare achieved sustained improvement for two of three Provider Satisfaction study indicators. SFY 2012 External Quality Review Annual Report State of Georgia Page 5-7 GA2011-12_EQR_AnnRpt_F2_0612 PERFORMANCE IMPROVEMENT PROJECTS Conclusions PIP performance measure outcomes showed mixed results, with some achieving improvement and others demonstrating a decline. An analysis of the interventions related to PIPs demonstrating improvement (Peach State and WellCare) suggested their successful PIP performance measure outcomes may be the result of the CMOs' strong link between identified barriers and interventions, the timing of the interventions, and the selection of interventions for system change. AMERIGROUP had the greatest challenge with achieving improved outcomes, which could be due to the CMO's lack of documented barrier analysis and interventions. Other PIPs that did not have performance measure improvement had key factors that may have prevented the desired outcomes. HSAG noted that for these PIPs without improvement, the CMOs did not always implement new or revised strategies, did not implement interventions in time to have an impact on the measurement period, or did not implement interventions for system change. Recommendations The CMOs need to thoroughly document their barrier analysis, the barriers identified, and the subsequent prioritization of the barriers for every measurement period, at a minimum. The CMOs should only document interventions that address the identified barriers. Ongoing interventions that do not directly address barriers impeding improvement do not contribute to the evaluation of improvement strategies. The CMOs should select interventions for system change that increase the likelihood of achieving and sustaining improvement instead of one-time interventions. The CMOs should develop and document a method to evaluate the efficacy of each intervention. The CMOs should use the results of the interventions' evaluation to determine whether each intervention should be continued or revised. DCH and the CMOs should continue to explore and develop areas for collaboration on the DCH-required PIPs. While the CMOs are required to conduct PIPs for the DCH-selected topics, they have not collaborated on improvement strategies. HSAG has identified collaborative improvement strategies in conjunction with CMO-specific strategies as an effective approach to improve PIP outcomes. SFY 2012 External Quality Review Annual Report State of Georgia Page 5-8 GA2011-12_EQR_AnnRpt_F2_0612 6. CMO-Specific Follow-Up on Prior-Year Recommendations Introduction This section presents the CMOs' improvement actions taken in response to HSAG's recommendations included in its prior-year (SFY 2010) External Quality Review Annual Report for the Georgia Families Care Management Organizations (CMOs). The recommendations were the result of HSAG's prior-year EQRO activities and findings from its: Review of the CMOs' compliance with the federal Medicaid managed care structure and operations standards described at 42 CFR 438.214210 (i.e., provider selection, enrollee information, confidentiality, enrollment and disenrollment, grievance systems, subcontractual relationships and delegation) and with the associated DCH contract requirements.* Validation of the CMOs' PIPs. Validation of the CMOs' performance measures. * Specific to the compliance review, for each of the requirements for which HSAG found the CMOs' performance as not fully compliant, the CMOs were required to prepare and submit to DCH and, when approved, implement corrective action plans (CAPs) addressing each HSAG recommendation. The CMOs were also required to provide to DCH documentation related to implementing its CAPs. AMERIGROUP Community Care Review of Compliance With Operational Standards As a result of the compliance reviews conducted in CY 2009 and 2010, AMERIGROUP was required to implement corrective actions for 29 requirements. HSAG reassessed these deficient areas during the review conducted in August 2011 and determined in its follow-up review that the CMO had implemented sufficient corrective actions to bring its performance into compliance with 27 of the 29 requirements. Corrective actions included revising policies and procedures, desktop procedures, the member handbook, and the provider manual. Two elements remained noncompliant as reported in the February 2012 compliance report: In the Emergency and Poststabilization Services standard, AMERIGROUP did not fully satisfy the required action to revise the member handbook to explicitly state what the member is financially obligated to pay for poststabilization care services. In the Grievance System standard, AMERIGROUP must further revise its policies and procedures to address outstanding areas of noncompliance related to State administrative law hearings, the definition of a proposed notice of action, and time frames for requesting a continuation of benefits. Additionally, AMERIGROUP must revise its member handbook to include all required actions for which a member may request an administrative review. SFY 2012 External Quality Review Annual Report State of Georgia Page 6-1 GA2011-12_EQR_AnnRpt_F2_0612 CMO-SPECIFIC FOLLOW-UP ON PRIOR-YEAR RECOMMENDATIONS Validation of Performance Improvement Projects Prior-Year Recommendations Based on HSAG's prior-year validation results, AMERIGROUP had 70 evaluation elements that did not receive a Met score for its PIPs. HSAG recommended that: AMERIGROUP focus on the elements that received either a Point of Clarification or a score of Partially Met or Not Met, including those in Activities VII through IX, and make appropriate changes associated with those evaluation elements. AMERIGROUP ensure that the study is compliant with the DCH submission requirements including the required activities, data, and measurement periods. Follow-Up on Recommendations AMERIGROUP addressed the prior recommendations in its SFY 2011 PIP submissions. As applicable to the individual PIP, it: Submitted the required activities. Included the appropriate measurement periods. Documented its barrier analyses and improvement strategies. Additional CMO improvement actions included those specific to designing the studies and selecting and strengthening interventions. Specific to the Study Design: Used multidisciplinary staff with input from its Medical Advisory Committee to evaluate interim HEDIS results quarterly and assess the efficacy of the CMO's interventions for continuation or revision. Analyzed the demographics of its population to include gender, age, race, ethnicity, and geographic location, and developed additional interventions based on subgroup analysis to target subpopulations. Specific to Interventions: Continued a Strategic Outcomes and Analysis provider report, which included missed opportunities as well as lists of members due for preventive services for the lead screening in children, well-child visits, and childhood immunizations HEDIS measures. Initiated an incentive program to increase female well check-ups, based on subgroup analysis results. Added 97 providers to address geographic deficiencies. Continued a member incentive program for well-child visits and childhood immunizations. Added outreach associates to contact members not accessing appropriate services specific to lead screening in children, well-child visits, childhood immunizations, and adults' access to care. The CMO implemented TeleVox (robocalls) to contact these members. SFY 2012 External Quality Review Annual Report State of Georgia Page 6-2 GA2011-12_EQR_AnnRpt_F2_0612 CMO-SPECIFIC FOLLOW-UP ON PRIOR-YEAR RECOMMENDATIONS Enhanced the EPSDT tracking system to improve administrative data. Continued quarterly EPSDT medical record reviews to ensure provider compliance with the measures of well-child visits, childhood immunizations, and lead screening in children. Tracked and trended member grievances related to treatment dissatisfaction to identify opportunities to improve physician/member relationships and communication. Validation of Performance Measures Prior-Year Recommendations: Although AMERIGROUP did not have any data collection and reporting issues related to the measures, the CMO's performance on these measures suggested opportunities for improvement. HSAG recommended that AMERIGROUP focus quality improvement efforts in the areas of diabetes care and prenatal and postpartum care by conducting a causal/barrier analysis, evaluating existing strategies, and developing new, targeted strategies that address the identified barriers. Follow-Up on Prior Year Recommendations AMERIGROUP demonstrated strong improvement in the areas of diabetes care and prenatal and postpartum care. The plan had increased CY 2010 rates for all measures. Additionally, the plan achieved the performance target for HbA1c screening and for timeliness of prenatal care. AMERIGROUP has shown action to address these areas of low performance. Peach State Health Plan Review of Compliance With Operational Standards As a result of the CY 2009 and 2010 compliance reviews, Peach State was required to implement corrective actions for 26 requirements. HSAG determined in its follow-up review conducted in August 2011 that the CMO had implemented sufficient corrective actions to bring its performance into compliance with 21 of the 26 requirements. Corrective actions included modifying the cultural competency plan, revising policies and procedures, amending delegation agreements, and modifying the member and provider handbooks. The five elements that remained noncompliant are discussed further below. In the Member Information standard, there were three noncompliant elements found. Peach State did not fully satisfy the required action to revise the member handbook and the Members' Rights and Responsibilities policy. The revised member information was not complete, accurate, or understandable. Peach State must include in its member handbook and the Members' Rights and Responsibilities policy as appropriate: (1) complete information about the time frame for members' requests to continue benefits and the length of time these benefits may be continued; (2) accurate information about the State agency for complaints regarding compliance with advance directives; and (3) understandable information for members about their right to receive services in accordance with the Quality Assessment and Performance Improvement (QAPI) access standards. SFY 2012 External Quality Review Annual Report State of Georgia Page 6-3 GA2011-12_EQR_AnnRpt_F2_0612 CMO-SPECIFIC FOLLOW-UP ON PRIOR-YEAR RECOMMENDATIONS Two elements remained noncompliant in the Grievance System standard. Peach State must: correct and clarify member information to include all reasons (CMO actions) for which members could request an administrative review; remove information that the grievance process is available for these CMO actions; and make all CMO documents, including the notice of proposed action, consistent and complete with the information about the time frame for requesting continuation of benefits during an administrative appeal. Two remaining standards require continuing corrective action to correct and clarify member information to: Include all reasons (CMO actions) for which members could request an administrative review. Remove information that the grievance process is available for these actions. Make all CMO documents, including the notice of proposed action, consistent and complete with the information about the time frame for requesting continuation of benefits during an administrative appeal. Validation of Performance Improvement Projects Prior-Year Recommendations Peach State had 13 evaluation elements that did not receive a Met score according to the prior year validation results. HSAG recommended that: Peach State focus on and make appropriate changes to the evaluation elements that received a Point of Clarification, or a score of Partially Met or Not Met, including those in Activity VII and Activity IX. Peach State evaluate and document the efficacy of its interventions. Additionally, the plan should perform subgroup analysis to determine the appropriateness of and/or the necessity for targeted interventions. Follow-Up on Recommendations Peach State addressed the prior recommendations in its SFY 2011 PIP submissions. As applicable to the individual PIP, it: Conducted barrier analysis and subgroup analysis to evaluate the efficacy of interventions. Implemented a provider incentive program for lead screening in children, well-child visits, childhood immunizations, and adults' access to care. Performed subgroup analysis and developed targeted interventions to reduce avoidable emergency room visits for new members 1 to 10 years of age. Created a team to provide face-to-face support for providers in meeting HEDIS requirements. SFY 2012 External Quality Review Annual Report State of Georgia Page 6-4 GA2011-12_EQR_AnnRpt_F2_0612 CMO-SPECIFIC FOLLOW-UP ON PRIOR-YEAR RECOMMENDATIONS Validation of Performance Measures Prior-Year Recommendations Although Peach State did not have any data collection and reporting issues related to the measures, the CMO's performance on these measures suggested opportunities for improvement. HSAG recommended that Peach State focus quality improvement efforts in the areas of diabetes care and well-care visits by conducting a causal/barrier analysis, evaluating existing strategies, and developing new, targeted strategies that address the identified barriers. Follow-up on Recommendations Peach State improved its rates for all well-child/care measures during CY 2010. Additionally, the plan had good success with improving rates for many of the diabetes measures, including HbA1c testing, control, and medical attention for nephropathy. However, the plan had decreased rates for blood pressure control. Overall, Peach State demonstrated action to address these areas of low performance. WellCare of Georgia, Inc. Review of Compliance With Operational Standards As a result of the CY 2009 and 2010 compliance reviews, WellCare was required to implement corrective actions for 19 requirements. HSAG determined in its follow-up review conducted in August 2011 that the CMO had implemented sufficient corrective actions to bring its performance into compliance with 11 of the 19 requirements. Corrective actions included modifying the member and provider handbooks, revising policies and procedures, and amending training modules. The following eight elements remained noncompliant at the time the compliance report was released to the plan in February 2012: The first noncompliant element is in the Emergency and Poststabilization Services standard. The CMO's member handbook contained a statement that could possibly deter members from seeking emergency care. WellCare must revise or remove the member handbook statement that refers to the payment for emergency services based on the severity of symptoms. There were three noncompliant elements in the Member Information standard. The section of the member handbook that discussed emergency services advised members that they could receive these services without authorization as long as the plan was notified. The CMO must clarify this information in the member handbook so as not to imply that the member must notify the CMO for urgent and emergency services. WellCare must also improve the readability and understandability of the information it added to the member handbook related to members' financial liability for services. The correct time frames for requesting continuation of benefits must be stated, and the language used to describe how long the CMO will continue benefits when a member has requested continuation during an administrative review or administrative law hearing must be clarified. There were four noncompliant elements in the Grievance System standard. WellCare must make revisions to numerous documents (policies, handbooks, etc.) to SFY 2012 External Quality Review Annual Report State of Georgia Page 6-5 GA2011-12_EQR_AnnRpt_F2_0612 CMO-SPECIFIC FOLLOW-UP ON PRIOR-YEAR RECOMMENDATIONS correctly state the time frame for a member to request continuation of benefits during an administrative review or administrative law hearing. Finally, WellCare was required to define in its documents the circumstances and length of time for the continuation of the member's benefits. Validation of Performance Improvement Projects Prior-Year Recommendations WellCare had 11 evaluation elements that did not receive a Met score based on the prior year validation results. HSAG recommended that WellCare: Focus on and make appropriate changes to the evaluation elements that received a Point of Clarification or a score of Partially Met or Not Met, including those in Activities VII through IX. Evaluate and document the efficacy of its interventions. Additionally, the plan should perform subgroup analysis to determine the appropriateness of and/or the necessity for targeted interventions. Implement new and/or enhanced quality improvement strategies for these PIPs. Follow-Up on Recommendations WellCare reported that in response to HSAG's scores and points of clarification, the CMO took the following improvement actions or developed the following improvement plans: Launched a provider incentive program to reward PCPs for following the preventive health guidelines. Initiated an educational campaign to promote the PCP medical home, targeting members 5 to 8 years of age, based on subgroup analysis results. Implemented a member incentive program for completing all well-child visits, all immunizations, and a blood lead screening. Validation of Performance Measures Prior-Year Recommendations While HSAG determined that WellCare's processes related to data integration, data control, and performance indicator documentation were all acceptable, HSAG did recommend that WellCare focus quality improvement efforts in the areas of diabetes care and well-care visits by conducting a causal/barrier analysis, evaluating existing strategies, and developing new, targeted strategies that address the identified barriers. SFY 2012 External Quality Review Annual Report State of Georgia Page 6-6 GA2011-12_EQR_AnnRpt_F2_0612 CMO-SPECIFIC FOLLOW-UP ON PRIOR-YEAR RECOMMENDATIONS Follow-Up on Recommendations WellCare had improved CY 2010 performance for all well-child/well-visit indicators and nearly all diabetes measures. Based on these results, the plan has demonstrated action to address these areas of low performance. SFY 2012 External Quality Review Annual Report State of Georgia Page 6-7 GA2011-12_EQR_AnnRpt_F2_0612 Appendix A. Methodology for Reviewing Compliance With Standards The following is a description of how HSAG conducted the external quality review of compliance with standards for the CMOs. It includes: The objective for conducting the review. The technical methods used to collect and analyze the data. A description of the data obtained. HSAG followed standardized processes in conducting the review of each CMO's performance. Objective The primary objective of the compliance review was to provide meaningful information to DCH and the CMOs about the CMOs' compliance with federal measurement and improvement standards and the related DCH contract requirements. DCH and the CMOs can use the information and findings from the review to: Evaluate the quality, timeliness of, and access to care and services furnished to members. Identify, implement, and monitor interventions to improve these aspects of care and services. Technical Methods of Collecting and Analyzing the Data HSAG developed and used a data collection tool to assess and document the CMOs' compliance with the selected federal Medicaid managed care regulations, State rules, and the associated DCH contractual requirements. The review tool addressed the following performance areas: Availability of Services Furnishing of Services Cultural Competence Coordination and Continuity of Care Coverage and Authorization of Services Emergency and Poststabilization Services HSAG conducted on-site compliance reviews in August 2011. The CMOs submitted documentation that covered the review period of July 1, 2010, through June 30, 2011. HSAG provided detailed, final audit reports to the CMOs and DCH in February 2012. The on-site review in August 2011 was the first year of a three-year cycle of compliance reviews that HSAG conducted for the CMOs under its contract with DCH. HSAG requested and obtained from the CMOs documentation related to the standards and used this written information for its pre-on-site desk review. HSAG obtained additional information through interactions, discussions, system demonstrations, and interviews with the CMOs' key staff members during the on-site portion of the review. SFY 2012 External Quality Review Annual Report State of Georgia Page A-1 GA2011-12_EQR_AnnRpt_F2_0612 METHODOLOGY FOR REVIEWING COMPLIANCE WITH STANDARDS To draw conclusions about the CMOs' performance, HSAG aggregated and analyzed the data resulting from its desk and on-site review activities. HSAG used scores of Met, Partially Met, and Not Met to indicate the degree to which the CMOs' performance complied with the requirements. A designation of NA was used when a requirement was not applicable to a CMO during the period covered by the review. This scoring methodology was consistent with CMS' final protocol, Monitoring Medicaid Managed Care Organizations (MCOs) and Prepaid Inpatient Health Plans (PIHPs): A Protocol for Determining Compliance With Medicaid Managed Care Proposed Regulations at 42 CFR Parts 400, 430, et al, February 11, 2003. From the scores it assigned for each of the requirements, HSAG calculated a total percentage-ofcompliance score for each of the three standards and an overall percentage-of-compliance score across the three standards. HSAG calculated the total score for each of the standards by adding the weighted score for each requirement in the standard receiving a score of Met (value: 1 point), Partially Met (value: 0.50 points), Not Met (0 points), and Not Applicable (0 points) and dividing the summed, weighted scores by the total number of applicable requirements for that standard. Description of Data Obtained To assess the CMOs' compliance, HSAG reviewed a wide range of written documents produced by the CMOs, including the following: Committee meeting agendas, minutes, and handouts Written policies and procedures Clinical practice guidelines The provider manual and other communication to providers/subcontractors The member handbook and other written member informational materials Technical system specification manuals and on-site system demonstrations Narrative and/or data reports across a broad range of performance and content areas The following table lists the major data sources HSAG used in determining the CMOs' performance in complying with requirements and the time period to which the data applied. Table A-1--Description of Data Sources Data Obtained Time Period to Which the Data Applied Documentation submitted for HSAG's desk review and additional documentation available to HSAG during the on-site review (from the CMOs) July 1, 2010, through June 30, 2011 Information obtained through interviews with CMO staff members July 1, 2010, through June 30, 2011 HSAG provided CMO-specific reports to DCH and the CMOs containing detailed information about the process and findings from the review of compliance with standards. SFY 2012 External Quality Review Annual Report State of Georgia Page A-2 GA2011-12_EQR_AnnRpt_F2_0612 Appendix B. Methodology for Conducting Validation of Performance Measures The following is a description of how HSAG conducted the validation of performance measures activity for the DCH Georgia Families CMOs. It includes: The objectives for conducting the activity. The technical methods used to collect and analyze the data. A description of the data obtained. Objectives The primary objectives of HSAG's performance measure validation process were to: Evaluate the accuracy of the performance measure data collected by the CMOs and DCH. Determine the extent to which the specific performance measures calculated by the CMOs or the State (or on behalf of the CMOs or the State) followed the specifications established for each performance measure. HSAG began performance measure validation in February 2011 and completed validation in June 2011. The CMOs submitted performance measure data that reflected the period of January 1, 2010, through December 31, 2010. HSAG provided final performance measure validation reports to the CMOs and DCH in July 2011. HSAG began performance measure validation of HP in March of 2011 and completed validation in December 2011. HSAG provided the final performance measure validation report to DCH in March of 2012. Technical Methods of Data Collection and Analysis HSAG conducted the validation activities as outlined in the CMS publication, Validating Performance Measures: A Protocol for Use in Conducting External Quality Review Activities, final protocol, Version 1.0, May 1, 2002. Pre-on-site activities and document review were conducted, followed by an on-site visit to each CMO and HP that included interviews with key staff and system demonstrations. Finally, post-review follow-up was conducted with each CMO and HP on any issues identified during the site visit. Information and documentation from these processes were used to assess the validity of the performance measures. The CMS protocol identified key types of data that should be collected and reviewed as part of the validation process. The list below describes how HSAG collected and analyzed these data: An Information Systems Capabilities Assessment Tool (ISCAT) was requested from each CMO as well as DCH and its subcontracted vendor, HP. HSAG conducted a high-level review of each ISCAT to ensure that all sections were completed and all attachments were present. The validation team reviewed all ISCAT documents, noting issues or items that needed further follow-up, and began completing the review tools, as applicable. Source code (programming language) for performance indicators was requested. Each CMO and HP submitted source code for measures that were not calculated using NCQA-certified SFY 2012 External Quality Review Annual Report State of Georgia Page B-1 GA2011-12_EQR_AnnRpt_F2_0612 METHODOLOGY FOR CONDUCTING VALIDATION OF PERFORMANCE MEASURES software. HSAG completed line-by-line code review and observation of program logic flow to ensure compliance with performance measure definitions. Areas of deviation were identified and shared with the lead auditor to evaluate the impact of the deviation on the indicator and assess the degree of bias (if any). Supporting documentation included any documentation that provided reviewers with additional information to complete the validation process, including policies and procedures, file layouts, system flow diagrams, system log files, and data collection process descriptions. The validation team reviewed all supporting documentation, with issues or clarifications flagged for further follow-up. The following table displays the data sources used in the validation of performance measures and the time period to which the data applied. Table B-1--Description of Data Sources Data Obtained Roadmap (From the CMOs) Source Code (Programming Language) for Performance Measures (From the CMOs and DCH) Supporting Documentation (From the CMOs and DCH) Current Performance Measure Results (From the CMOs and DCH) On-site Interviews and Demonstrations (From the CMOs and DCH) Time Period to Which the Data Applied CY 2010 CY 2010 CY 2010 CY 2010 CY 2010 SFY 2012 External Quality Review Annual Report State of Georgia Page B-2 GA2011-12_EQR_AnnRpt_F2_0612 METHODOLOGY FOR CONDUCTING VALIDATION OF PERFORMANCE MEASURES Table B-2--Utilization Domain Measures, CMO Comparison AMERIGROUP Peach State Health Plan WellCare Measure Rate CY 2010 Percentile Rank1 Symbol Rate CY 2010 Percentile Rank Symbol Rate CY 2010 Percentile Rank Symbol Inpatient Utilization--General Hospital/Acute Care Total Inpatient Discharges Per 1,000 Member 6.9 P10P24 6.8 P10P24 Months Total Inpatient Days Per 1,000 Member Months 23.1 P10P24 22.5 P10P24 Total Inpatient Average Length of Stay 3.4 P25P49 3.3 P25P49 Medicine Discharges Per 1,000 Member Months 1.1 P90 30.2 >P90 Maternity Average Length of Stay 2.8 P50P74 2.7 P50 1 CY 2010 percentile rank was based on NCQA's 2010 Audit Means, Percentiles, and Ratios. Below 25th Percentile 25th74th Percentile 75th Percentile or Above 6.6 P10P24 21.3 P10P24 3.2 P25 1.4